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HomeMy WebLinkAbout49571-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 PLAN'S AND SPECIFICATIONS UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Permit#: 49571 Date: 8/14/2023 Permission is hereby granted to: Peconic Coastal Prop LLC PO BOX 545 Southold NY 11971 To: Modification to existing wireless communication tower: Verizon Wireless: including removal of(9) antennas and (6) RRHS; install (12) New Antennas, (6) RRHS, (2) OVPS, and (2) Hybrid Cables, as applied for and per Planning Board approval & conditions. At premises located at: 415 Eli'ahs Ln, Mattituck SCTM # 473889 Sec/Block/Lot# 108.-4-11.3 Pursuant to application dated 6/27/2023 and approved by the Building Inspector. To expire on 2/12/2025. Fees: WIRELESS COMMUNICATIONS -MODIFICATIONS $500.00 CO-COMMERCIAL $50.00 Total: $550.00 Building Inspector � warcTOWN OF SOUTHOLD—BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. O. Box 1179 Southold, NY 11971-0959 r Telephone (631) 765-1802 Fax (631) 765-9502 litlittps: .s uth+ ldtowi Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only PERMIT NO, Building Inspector: .-w JUN 2 l 2023 Applications and forms must be filled out in their entirety. Incomplete applications will not be accepted. Where the Applicant is not the owner,an ..� - Drser's.Autharization 1"in 4.Page 24 shall be z^_,,..pkaed _ Date: 6/26/2023 OWNER(S) OF PROPERTY: Name:Peconic Coastal Properties, LLC SCTM# 1000-108-4-11 .3 Project Address:415 Eiljah's Lane, Mattituck, New York 11952 Phone#: Email: Mailing Address:c/o: their Attorney-in-Fact SBA Towers IX LLC, by its Attorney-in-Fact, NCWPCS MPL22—Year Sites Tower Holdin s LLC b it Attorn -in-Fact CCATT LLQ PO BOX 545 Southold New Y rk 11071 CONTACT PERSON: Name:c/o Gabriella Amato, Esq, of Amato Law Group, PLLC Mailing Address:666 Old Country Road,, Suite 901 , Garden City,, New York 11530 Phone#:(516) 227-6363 1 Email:GAmato@amatofirm.com DESIGN PROFESSIONAL INFORMATION: Name:Peter D. Smith, P.E., of B+T Group Mailing Address:1717 S. Boulder, Suite 300, Tulsa, Oklahoma 74119 Phone#:(918) 587-4630 Email:marvin.phillips@btgrp.com CONTRACTOR INFORMATION: Name:Comcell Construction Corp. Mailing Address:1373 Lincoln Avenue, Holbrook, New York 11741 Phone#:(631 ) 654-5915 Email:Fran@com-cell.com DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: [s]Other* $30,000.00 Will the lot be re-graded? ❑Yes ®No Will excess fill be removed from premises? Dyes ®No Nserizdn ir'eiess`"), the Applicant Brien, proposes to upra its existing public utility wireless communication facility located at the above-referenced property, as more fully reflected in the construction drawin s submitted herewith and in or casted hereir►. 1 PROPERTY INFORMATION Existing use of property:Public utility wireless communication facility Intended use of property:Public utility wireless communication facility Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to Industrial this property? ❑Yes A No IF YES, PROVIDE A COPY. Check Box After Reading: The owner/contractor/design professional is responsible for all drainage and storm water issues as provided by Chapter 236 of the Town Code. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the Building Zone of buildings, econstruction , or forth g Laws Ordinances Ordinance of the Town of Southold,Suffolk,County,New York and other applicableRegulations, 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.. , on behalf of Applicant/Lessee New York SMSA Limited Partnership ',Authorized Agent ❑Owner Application Submitted By(print name): d/b/a Verizon Wireless Signature of Applicant„ Date: 5/31/2023 Title: Netw�EnqngRealEstate STATE OF NEW YORK) SS: COUNTY OF „>) 6 being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract) above named, he is the _ _.....�............. _._ Applicant/Lessee 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 i rklpn "'� ° M ` ] W YORK n da of 20 A OpN q. ubIIC i..� V t`.,it�1.w"A ✓0� PROPERTY E AUTHORIZATION (Where the applicant is not the owner c/o:the'Ir Attorney-in- act SBA Towers IX LLC, by its Attorney-in-Fact, NCWPCS 9' PL —Year Sites Jenifer Bachi, on behalf of Peconic Coastal Tower Holdings LLC„ by its Attorney-in-fact, CCATT I Properties, LLC residing at LL 'C) Baas 5 5�Sp :tholdro•.' .York 11971 New York SMSA Limited Partnersh d/b/a Verizon Wireles, do hereby authorize c/o Amato Law Groyp, PLL.0 _ _._to apply on my behalf he Town of Southold Building Department for approval as described herein. ner's Signature Date gnifer Ra hi .bite Ar: t ion S i l " Print Owner's Name 2 MAILING ADDRESS: PLANNING BOARD MEMBERS P.O. Box 1179 DONALD J.WILCENSKI " Southold, NY 11971 Chair " � OFFICE LOCATION: JAMES H. RICH III Town Hall Annex MARTIN SIDOR 54375 State Route 25 PIERCE RAFFERTY (cor.Main Rd. &Youngs Ave.) AMELIA JEALOUS-DANK # Southold, NY Telephone: 631 765-1938 www.southoldtownny.gov PLANNING BOARD OFFICE TOWN OF SOUTHOLD MEMORANDUM o AUG 11 2023 To: Michael J. Verity, Chief Building Inspector Building Department Town of Southold From: Heather M. Lanza, AICP, Planning Director wwx Date: August 11, 2023 Re: Planning Department Report Equipment Upgrade for Verizon Wireless at 415 Elijah's Lane 415 Elijah's Lane, Mattituck SCTM#1000-108.-4-11.3 The Planning Department has conducted a review of the proposed modifications referenced above pursuant to §280-74 B(2), and has received a report from our Wireless Technical Consultant, Cityscape, Inc. (see attached report). The proposed Verizon equipment upgrade is in compliance with the General Requirements of§280-70. The proposed equipment upgrade will cause essentially no visible change to the exterior by removing and replacing antennas and radio heads, in addition all cables will be routed inside the shaft of the monopole. There is no proposed change to ground equipment. Therefore, we recommend a Building Permit be issued for this application as soon as possible to meet the Federal shot clock rules for approvals of modifications to wireless facilities. Laserfiche File: Planning Department/Applications/Site Plans (SP)/Pre- submission/1000-108.-4-11.3(6) Thank you for your cooperation. cc: Gabriella S. Amato, Esq., Amato Law Group Town o Southold New York CRyScape Telecommunications Review C 0 N S U L T A N T S , I N C . Wl atio Application 2423 S.Orange Ave#317 Orlando,FL 32806 Tel:877.438.2851 Fax:877.220.4593 July 17, 2023 Heather Lanza Town of Southold Town Hall Annex Building 53095 Route 25 Southold,NY 11971 PROVIDER/NAME/ID: Verizon Wireless/Mattituck/ 144803 TOWER OWNER/NAME/ID: Crown Castle/BU#843211 /Mattituck ADDRESS: 415 Elijah's Lane, Mattituck,NY 11952 LATITUDE: 40' 59' 57.79"N LONGITUDE: 72' 30' 40.17"W S CTM#: 1000-108.4-11.3 STRUCTURE: 107.5' Existing Monopole Tower(110.5' including appurtenances) Dear Ms. Lanza, At your request,on behalf of the Town of Southold("Town"), CityScape Consultants, Inc. ("CityScape"), in its capacity as telecommunications consultant for the Town, has considered the merits of the above-referenced application submitted on behalf of Verizon Wireless ("Applicant") to modify equipment on an existing one hundred and seven and a half(107.5)foot monopole tower. The tower, owned by AT&T and Crown Castle (and is managed by Crown Castle), is located at 415 Elijah's Lane, Mattituck, New York, see Figure 1. AT&T, Dish and T-Mobile also operate at this site. ucart Structure& EaUiDment Per the submitted construction drawings (CDs)I the Applicant proposes to remove nine (9) antennas and six(6)Remote Radio Heads(RRHs)at the seventy-eight(78)foot level of the tower. The Applicant proposes to install new equipment, as shown in the table below, on the existing Verizon antenna mount located at the seventy-eight(78)foot level of the tower,see Figures 2 and 3. TOWER EQUIPMENT # ADD 12 Antennas:6)Commscope NNH-6513-11261;3)Samsung XXDWMM-12.5-65; 3)Samsung MT6407-77A 6 RRH's:3)Samsung 132/1368A;3)Samsung 135/1313 2 Hybrid cables 1-1/4" 1 CD's prepared by B+T Group,Rev 5"Construction"dated 6/16/23,signed and sealed by a registered New York Professional Engineer. Town of Southold—SCTM# 1000-108.4-11.3 CKYSCaW%Mk Verizon/ 144803 Page 2 CON SU LTA N T s , INC . At ground level in the compound, the Applicant has no changes to its equipment that is located within Verizon's shelter inside the tower's compound,see Figure 4. Structural Analysis The Applicant submitted a Structural Analysis Report (SA) prepared by Tower Engineering Professionals, dated April 4,2023,based on ANSI/EIA/TIA-222-H,Risk Category II and Exposure Category C standards. The analysis indicates that, after the Applicant's proposed modifications, the tower would be at 93.5% of maximum usage capacity (out of an allowable 105%). Thus, it is determined that the structure, with the proposed modifications, would be structurally compliant, see Figure 5. The two (2) new hybrid cables that will be added will be routed inside the monopole as indicated on the SA. Since the Applicant will be using its existing antenna mount,a Mount Analysis Report was submitted. The report was prepared by NB+C, dated June 24, 2022 and utilized the same criteria as the SA referenced above. The analysis concludes the max structure rating is at 36.2% which falls within the acceptable range,see Figure 6. RF Exposure Safety To verify RF exposure safety, A Radio Frequency— Electromagnetic Energy (RF-EME) Report from EBI Consulting, dated 7/7/2023 was submitted by the Applicant showing FCC compliance with RF exposure rules at no more than 20.6% of the FCC limits for public RF exposure,see Figure 7. gumma _ roval Recommended CityScape verified this application to be an eligible facilities request and meets the definition of a non-substantial change ("substantial change" being defined in 47 CFR §1.6100(b)(7) of the FCC Rules). Therefore, this application qualifies for streamlined processing at staff level under 47 CFR§1.6100(c) and Cityscape recommends approval. Town of Southold—SCTM# 1000-108.4-11.3 CRYSOMW%Aft Verizon/ 144803 Page 3 C O N S U L T A N T S , I N C . I certify that, to the best of my knowledge, all the information included herein is accurate at the time of this report. CityScape only works for public entities and has unbiased opinions. All recommendations are based on technical merits without prejudice per prevailing laws and codes. Cityscape verified that the proposed appurtenances shown by Applicant's construction drawings were listed in the structural report,but we did not independently verify the calculations, statements or the appropriateness of the analysis criteria contained therein. Town staff should verify compliance with applicable building and fire codes prior to issuance of a permit for this modification. Respectfully submitted, Xt Steven Webster Project Engineer CityScape Consultants, Inc. Town of • • • 111 1: Iftigm Ckyscato1w Verizon/ 44:1 Page 4 • u 25 Figure 1 —Site a 14 Andes J!��nsen C�esiign �r���' Tem�����r,aril;��clla"srd r Advance Auto Pmts d r r r� Lin Island Tick Test�n Location Map Town of Southold—SCTM# 1000-108.4-11.3 ChYrocaw%Aft Verizon/ 144803 VFW Page 5 C 0 N s u L T A N T S I N C : .. . FA4 MPROYED IbGTR: 1'-0'AM JUN 2 B 2023 —&)ielnT°d own Maiiiiino Board TOP Lw' OnuETTT'� 7 N2Y1P MI�4FYSIX'+NiYG ' r.^^.^.-,..VAW WM20"EOUMEM ""'' ffi [••i3Wd_09-W0 AMENIAS SAMSUM 55sl C:fbltRl SJWSUM-945/EIO]DPA $)SWSLR2G-N13'6x6"5..']7rN AtiPEN:TptS Y SIWSLNO_Kat,DN-331$2.5-SSS � ON EMIM<W N4Mi7NE5 '^ (E)VERIZON MOMENT 10 REU M RAY -R%%DC-3315-PF-4a tivSTALIED ON Er97,NG MCUhlS AN�Eh7N 1-V MOW CL.7e'�- , I� ,1 u� .;w„�......-...e..r.........w,...... (E)107•-6•Mdi0701E u ..__..._ ..�.. +ws rr4s drb wwo CAR;.r 41 $2 " . Np'vEOx25N REMAtS ..a... )KMRO CAaf(I-1/45 I �-po R 7 TOWERELEVATION aCALE: NOT TO SCALL Figure 2—Elevation Drawing of Structure& Proposed Equipment Town of Southold-SCTM# 1000-108.4-11.3 ckyscawwk Verizon/ 144803 MW Page con SULTANTs , INc , C■ IxA RE ROKNCO (GA44A) BOER -NI1049 332,AZNAuTN 13'TOTAL,,.1 PER SECTOR)' c3 �1 cz „.. ■ Ai (EI CVP TO REMNN RAYCAP-R%%OC-13tS-Pi-�B (E)PLATFORM MOUNT°—%.,,. ,a✓*`„N'.' �y CI ,,,,....•-( A(�REtlFP4A`vIC BE'RNTdS140 10 RENNM ••'A2I P (a TOTAL. PER SECT OR) Aj �w�••, (A1PTM) ]D'kIMUTN (BETA) AA ""�(E)RRN TO OE RE!Y4YU 245 AZIMUTHR2 �U'-R9/Or3 RRN-ORDEC "°�y (]TOTILL,1 PTA SMOR) EXISTING ANTENNA PLAN SCALEfm .. \ CI ,•_S�WSM-B2/BE6A CRAN -wed J�„''" (RfM79D-LSA) 3 TOTAL 1 PER SECTOR) [] µ...-NEW ANTENNA COAMLS -RNSSR-It2B (e TOTAL AL 2 2 PER SECTOR) EnWR/R,TE, Of RC3OC-331:-PF-48 New Ow RAYYCAP R=C-3315-PF-4B (2 TOTAL) SWSUh'O-BS/BIS OPAN (RFAMOD-Iw J As QRy ,.sW' (3 TOTAL 1 PER SECT)R) "h..�! p.E�tlO'F.ra.,-,✓ "'", eT'D`Au+Wv,)@j.. ht-SUB! x r B] (3 TOTAL.1 00 SECTOR,) A (E)PUTFONM MOUNT^^�^'" 7AYRE7AZWUM NL-SU96 AA VIC (3.TOTAL 1 PER SECTOR) LAN %AL NOT TO Figure 3-Overhead View of Existing and Proposed Equipment Configuration Town of Southold—SCTM# 1000-108.4-11.3 cItYr0caw%Aft Verizon/ 144803 ljpqw Page 7 CON SU LTA N T S , I N C JUN ES 2023 j �"�"* Nrvnmaa3np � v= 0 u 1. P � � J e a l ti, { Figure 4—Ground Equipment Configuration Town of Southold—SCTM# 1000-108.4-11.3 Verizon/ 144803 CkySCa*VqW Page 8 C O N S U L T A N T S I N C Date: April 4,2023 Tower Engineering Professionals 326 Tryon Road Raleigh,NC 27603 (919)661-6351 Subject: Structural Analysis Report Carrier Designation: Verizon Wireless Co-Locate Site Number: 5000193684 Site Name: Mattituck Crown Castle Designation: BU Number: 843211 Site Name: Mattituck JDE Job Number: 745021 Work Order Number: 2217925 Order Number: 648700 Rev.0 Engineering Firm Designation: TEP Project Number: 218919.839766 Site Data: 415 Elljahs Lane,Mattituck,Suffolk County,NY 11952 Latitude 40°59'57.79",Longitude-72°30'40.17" 107.5 Foot-Monopole Tower Tower Engineering Professionals is pleased to submit this "Structural Analysis Report" to determine the structural integrity of the above-mentioned tower. The purpose of the analysis is to determine acceptability of the tower stress level.Based on our analysis we have determined the tower stress level for the structure and foundation,under the following load case,to be: LC7:Proposed Equipment Configuration Sufficient Capacity This analysis utilizes an ultimate 3-second gust wind speed of 128 mph as required by the 2020 New York State Uniform Code.Applicable Standard references and design criteria are listed in Section 2-Analysis Criteria. Structural analysis prepared by: Gautam Sopal,E.I./DEN Respectfully submitted by: ,R" P H p 1k �' Adam N.Howe,P.E. f069s6 S'stt" 4-4-2023 RECEIVED LJUN 2 8 2023 outhold Town Planning Board Figure 5—Structural Analysis Summary Town of Southold—SCTM# 1000-108.4-11.3 ruft Verizon/ 144803 CkysicavARW Page 9 C ON S U L T A N T S , INC Am z TED ri TOTALLY COMMITTED Network Building+Consulting,LLC 1777 Sentry Parkway W,Veva 17 Suite 400 Blue Bell,PA 19422 (267)460-0122 NBC_SmartTool@nbcllc.com Antenna Mount Analysis Report and PMI Requirements Mount Analysis SMART Tool Project#:10150854 NB+C Project M 100895 June 24,2022 site .p n, Site ID: 144803-VZWIMATTITUCK Site Name: MATTITUCK Carrier Name: Verizon Wireless Address: Elijah's Lane 8 RT 25 Southold,New York 11952,Suffolk County Latitude: 40.999360° Longitude: -72.511400° Structure Information Tower Type: 107.5-Ft Monopole Mount Type: 12.5-Ft Platform Mount FUZE ID#16275828 Analysis Results Platform: 36.2%Pass* *.Antennas and equipment to be Installed In compliance with PMI Requirements of this mount analysis. * r LN ftguiremaym Included at the end of this MA report Available&Submitted via portal at https://pmi.vzwsmart.com For additional questions and support,please reach out to: vzwpmisupport@nbcllc.com of NEIV Report Prepared By:Rachel Huang,P.E. `�' oorb 6!2412022 4410 wc Figure 6—Mount Analysis Summary Town of Southold—SCTM# 1000-108.4-11.3 CRYSIOMIAM Verizon/ 144803 Page 10 c o N s u 1. T A N T s I N c , Radio Frequency - Electromagnetic Energy (RF-EME) Jurisdictional Report Site No. 144803 Mattituck Elijah's Lane&Rt 25 Southold,New York 11952 Suffolk County 40°59' 57.70"N.-72°30' 41.00"W NAD83 EBI Project No.6223002739 July 7.2023 i u ,rc,�ww E level, the maximum cumulative exposure level from all carriers at this Site is approximately ent of the FCC's general population limit (4.126 percent of the FCC's occupational limit). y, at the adjacent rooftops and ground, the maximum cumulative exposure level from all this Site is below both the FCC's general population and occupational limits. Prepared for. Verizon Wireless 4 Centerock Road West Nyack.NY 10994 Prepared by: Consulting a environmental I engineering I due diligence Figure 7—EME Compliance Report Title Page with Report Conclusions YNOEWRX Workers' CERTIFICATE OF INSURANCE COVERAGE ..� srArr Compensation Board 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) F631-654-5915 Business Telephone Number of Insured COMCELL CONSTRUCTION CORP. 1373 LINCOLN AVENUE HOLBROOK, NY 11741 Work Location of Insured(Only required if coverage is specifically limited to 1 c.Federal Employer Identification Number of Insured certain locations in New York State,i.e., Wrap-Up Policy) or Social Security Number 27-0807207 ................ 2.Name and Address of Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Standard Security Life Insurance Company of New York Town of Southold 54375 Main Road 3b.Policy Number of Entity Listed in Box"1 a" Southold, NY 11971 R90293-000 3c.Policy effective period 1/1/2013 to 2/7/2024 4. Policy provides the following benefits: ❑X A. Both disability and paid family leave benefits. ❑ B.Disability benefits only. ❑ C.Paid family leave benefits only. 5. Policy covers: 0 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 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 desc' yd above. Date Signed 2/8/2023 �,. BY (Signature of insurance carrier's auuY.horgy d aegnre",entaC.rve ar NY5 Licensed Insurance Agent of that insurance carrier) Telephone Number (212) 355-4141 Name and Title SUPERVISOR-DBL/POLICY SERVICES 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 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 sB 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 Signed BY (Signature of Authorized NYS Wuikeu'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 insurence 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 (10-17) II iIII lll DB-120.1 (10-17) Additional Instructions for Form D13-120.1 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 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 expirations 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 alter 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 (10-17) Reverse COMCCON-01 TEASE V ACORO` TDATE(MMIDD/YYYY) �� CERTIFICATE OF LIABILITY INSURANCE (MM' 23 _._........... ..____............ .....� .www 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 ri, ht�the certificate holder in lieu of such endorsement(s). PRODUCER License#BR-870302'.. c N ncrDarleen Aslanis, Ext. 161 Millennium Alliance Group,LLC PHONE _ FAX __M"' .. 534 Broadhollow Rd. Arc« qjr,Ext )496 8004 161 IA O,No)^ Ste.103 E-MML s,Aslanis .....map-insurance.commm ..... _ ..... Melville,NY 11747 INSURER(Si AFFORr),ING,COVFEd$AOE Ta,A,q,C INSURER A:Americani Empire Surplus_l_mes Insurance Co 38361 INSURED snlstaRe�B Merchants Preferred Insurance wwCom an 12901 Corpc:RSUI Indemnity Insurance Compan 22314 Comcell Construction INSURER .-._. .. ..". 1373 Lincoln Avenue IN,5VRERD,;;Arch Specials Insurance Co 21199 Holbrook,NY 11741 INSURER E•Litaerk,y Insurance Underwriters Inc.. ...... 19917 w.. INSURER F: COVERAGES CERTWICATE NUMBER: _. 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. ADDL SUER POLICY EFF POLICY EXP TYPE OF INSURANCE PI tJ..IR:..�..®.. OLCY NUMBER LIMITS..lMMd:RO A X COMMERCIAL GENERAL LIABILITY $ 1,000„000 E.A HOCC RRENCE ........_ CLAIMS-MADE X OCCUR PLE73784301 7/8/2022 7/8/2023 DAN ACLT'O RENTED $ 50,000 X . SLi43 �t ....__. MED EXP An one eerson,i,,. .. ....... PERSONAL a ADV INJURY $ 1,000 000 _._ 2,000 000' GATE LIMIT �ENERALAGGREGET POLICY AGGRE E..G $ �.. GEta PoucYE X PRO-Appose OEC PRnoucTsOOMp QP AGO $ 2,000 000 JECT OP"HEk GAT 5,000,000 .._........___.. -. ........ ._.._....... AM••!O,MBIINNED SINGLE ....1,000,000 B AUTOMOBILE LIABILITY X ANY AUTO CAP1052866 7/8/2022 7/8/2023 BODILY INJURY(Perperson),_, $"IT . ., OWNED SCHEDULED AUTOS ONLY AUTOS .BODILY INJURY LPer,accident� HIRED NO,N• NE PROPERI AMAGE ” AUTOS ONLY AIrrClC,JNI. r accdtltwa&...... ,,,,,..... ..�... $ ...... C �' 2 000,000 '..UMBRELLA LIAB �.. X OCCUR EACH OCCURRENCE $ X EXCESS LIAB CLAIMS-MADE NHA094791 7/8/2022 7/8/2023AGGREGATE $ 2,000,000' DED � RETENTION$��� OTH $ WORKERS COMPENSATIONER . Y/N AND EMPLOYERS'LIABILITY """'.PER 7 ANY PROP IETO /PARTNER/EXECUTIVE .I EACHACCtDEN7 _.. $ ,,,, OFFICER/MEMBER EXCLUDED? F7 NIA _2 ............. Mandato In NH ..L..DISEASE EA EMPLOYEE $ If yes,describe under ESCRIPTIQN QF Q"PERATIONS Below "EA..DISEASE-POLICY LIMIT ,$ D Excess Liab. UXP104528401 L71812022 718/2023 Per Occ/Per Agg 3,000,000 E Excess Liab. 1000352540-03 7/8/2023 Per Occ/Per Agg 5,000,000 DESCRIPTIDN OF OP'BRATI4NS!LOCATIONS R VEHICLES( k�8�Schedule,may b d or space qui�I) LES ACORD 101,Adel tional Remarks Y e attached If mores ace is rm yuir Equipment Floater Hartford Ins.Co.,Policy#12MSJE•30329/14/22 9/14123$250,000 limit for lease equipment. Installation Floater-Hartford Ins.Co.Policy#12MSJE3032 9/14/22-9/14/23$1,000,000 limit. Pollution Liability-Markel Insurance Co.-Policy#MKLCIENV100512 2/17/2022-2/17/2023 $1,000,000 Condition Limit/2,000,000 Agg.Limit. Town of Southold,54375 Main Road,Southold,New York,11971 is included as additional insured as required by written contract. _...... ........ CERTIFICATE HOLDFR _.. . 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. 54375 Main Road Southold,NY 11971 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 17-t1�1*\- NYSIF New York State Insurance Fund PO Box 66699,Albany,NY 12206 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE W" .CJ ^^^^^^ 270807207 MILLENNIUM ALLIANCE GROUP LLC 534 BROADHOLLOW RD STE 103 FEE µ. MELVILLE NY 11747 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER COMCELL CONSTRUCTION CORP TOWN OF SOUTHOLD 1373 LINCOLN AVENUE 54375 MAIN ROAD HOLBROOK NY 11741 SOUTHOLD NY 11971 POLICY NUMB11 ER CERTIFICATE NUMBER POLICY PERIOD DATE 12108505-5 776439 08/02/2022 TO 08/02/2023 2/8!2023 :1 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2108 505-5, 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 POLICYHOLDERS 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:I NYSIF,COMICERTICERTVAL.A,SP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THE POLICY INCLUDES A WAIVER OF SUBROGATION ENDORSEMENTUNDER WHICH N'YSIF AGREES TO WAIVE ITS RIGHT OF SUBROGATION TO BRING AN ACTION AGAINST THE CERTIFICATE HOLDER TO RECOVER AMOUNTS WE PANTO IN WORKERS"COMPENSATION ANO/OR MEDICAL BENEFITS TO OR ON BEHALF OF AN EMPLOYEE OF OUR INSURED IN THE EVENT THAT PRIOR TO THE DATE OF THE ACCIDENT, THE CERTIFICATE HOLDER HAS ENTERED INTO A WRITTEN CONTRACT WITH OUR INSURED THAT REQUIRES THAT SUCH RIGHT OF SUBROGATION BE WAIVED. 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 ST, T SUR' NCE FUND 4 �V DIRECTOR,INSU'RANGE FUND UNDERWRITING VALIDATION NUMBER: 922430604 U-26.3