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HomeMy WebLinkAbout49623-Z TOWN OF SOUtHOLU $ 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#: 49623 Date: 8/29/2023 Permission is hereby granted to: Domeluca II LLC 66 Leonard St 9C New York, NY 10013 To: construct accessory in-ground swimming pool as applied for per Trustees approval. At premises located at: 14895 Route 25 East Marion SCTM # 473889 Sec/Block/Lot# 23.1-2.10 Pursuant to application dated 3/20/2023 and approved by the Building Inspector. To expire on 2/27/2025. Fees: CO- SWIMMING POOL $50.00 SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 Total: $300.00 Building Inspector 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 Date Received BUILDINGAPPLICATION FOR For Office Use Only PERMIT NO Building Inspector: MAR 2 0 2023 � filled out in their entirety. Incomplete Applications and forms must be f tY ��. applications will not be accepted. Where the Applicant is not the owner,an E iLDN'Z DEPT Owner's Authorization form(Page 2)shall be completed. TmNOFSOMHOLD Date:03/03/23 OWNER(S)OF PROPERTY: Name:Pablo Salame scrM#1000-23-1-2.10 Project Address:14895 Main Rd. East Marion, NY 11939 Phone#: Email: Mailing Address:14895 Main Rd. East Marion, NY 11939 CONTACT PERSON: Name:Steven Affelt Mailing Address:PO Box 762 Great River, NY 11739 Phone#:(631) 553-6333 Email:steve.affelt@gmail.com DESIGN PROFESSIONAL INFORMATION: Name:Steven Affelt i, Mailing Address:PO Box 762 Great River, NY 11739 Phone#:(631) 553-6333 Email:steve.affelt@gmaiI.com CONTRACTOR INFORMATION: Name:Gibbons Pools Mailing Address:171 Bridge Rd Islandia, NY 11749 Phone#:(631) 851-3000 =Email:info@gibbonspools.com DESCRIPTION OF PROPOSED CONSTRUCTION []NewStructure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: DOther New Swimming Pool $200,000 Will the lot be re-graded? ❑Yes ig No Will excess fill be removed from premises? ❑Yes 5RNo 1 PROPERTY INFORMATION Existing use of property:Residential Intended use of property:Residential Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to R80 this property? ❑Yes lgNo IF YES, PROVIDE A COPY. ig Check Box After Reading: The owner/contractor/design professional is responsible for all drainage and storm water issues as provided by Chapter 236 of the Town Code. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the Building Zone Ordinance of the Town of Southold,Suffolk,County,New York and other applicable Laws,Ordinances or Regulations,for the construction of buildings, additions,alterations or for removal or demolition as herein described.The applicant agrees to comply with all applicable laws,ordinances,building code, housing code and regulations and to admit authorized inspectors on premises and in building(s)for necessary inspections.False statements made herein are punishable as a Gass A misdemeanor pursuant to Section 210.45 of the New York State Penal Law. Application Submitted By(print name):Seven Affelt RAuthorized Agent ❑Owner Signature of Applicant: Date: 03/03/23 STATE OF NEW YORK) SS: COUNTY OF Suffolk Steven Affelt being duly sworn, deposes and says that (s)he is the applicant (Name of individual signing contract) above named, (S)he i5 the Agent / Architect (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 the w' ith. Sworn before me this day of NJ 3 Not lic 'f ITTORIA M.JARYMISZYN Otary Public, State of New York PROPERTY OWNER AUTHORIZATI N0. 01JA6134762 Clualified in Suffolk County (Where the applicant is not the owns 3, 20 +C`.)mmission Expires October Pablo Salame residing at 14895 Main Rd. St Marion, NY 11939 do hereby authorize Steven Affelt to apply on my behalf to the Town of Southold Building Department for approval as described herein. Owner's Signature Date Pablo Salame Print Owners Name 2 Glenn Goldsmith,President Hall Annex A. Nicholas Krupski,Vice President 54375 Route 25 P.O. Box 1179 Eric Sepenoski Southold,New York 11971 Liz Gillooly Telephone(631) 765-1892 Elizabeth Peeples Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD July 24, 2023 Steven Affelt, AIA P.O. Box 762 Great River, NY 11739 RE: DOMELUCA II, LLC 14895 ROUTE 25, EAST MARION SCTM#: 1000-23-1-2.10 Dear Mr. Affelt: The following action was taken by the Southold Town Board of Trustees at their Regular Meeting held on Wednesday, July 19, 2023. RESOLVED that the Southold Town Board of Trustees APPROVE the Administrative Amendment to Wetland Permit#9863 to construct the previously (permitted; 1.8'2"x82' swimming pool rather than the 14'x82'1" swimming pool; with the condition of the replacement of five (5) native hardwood trees with a minimum of a 3" caliper; and as depicted on the site plan prepared by Gibbons Pools, received on June 9, 2023, and stamped approved on July 19, 2023. Any other activity within 100' of the wetland boundary requires a permit from this office. This is not an approval from any other agency. If you have any questions, please do not hesitate to contact this office. Sincerely, 44e"'.01 Aeichlas Krupsk" Vice-President, Board of Trustees AN K/dd ooOoV,d e� l ao i3a 33ts 105noH lNol 3a .� IMOISM 1tvi3C1)iovai l3llo 117J3iI`JNl`ao9Nf3a 13315 L Ntlld HIS 100d V1141 Q , a — — t ivl3a xoa a3wwi)ls f llVnO lll3016V 3 NVll woo Nla tl 1T m 3{lls _ pNOWIJ � 'V 3 oO°OOL-ia � 3�� V�tU YA.3u YO✓iroaLL Kli 9d _ - - £ - 33N301S3ll '�` .- NVId 3AS 100d `` c , r 1:1©1-11 r=1 ©gym® ©C�0 © IffD CO®1 OKI om® rlm®0= UQff:1© F—I ELI©0 ,H "D ONIalauv Tm'nivweLxJ TSN f, 53cch a�.2 M5 9m 1xb b � �� � � _ _ - 1trvuN5 SNu5o3 3u LL ' E . ,oy 3u ory a mwv�,Yal w e wu,. -ram':c - ` - se,avm�sonvs oa"'"m.o-v on ae wrrr,s�io�o r�iwu�Qn„v a.vaou3. `�-"�"�. € � � t _ •,�u:� r,v�, vHs a.d�-ov.�ren na'ua�a `� 4vaac .:u .ncui a.ua rlcn Stood SNO9915 _ . -� wa - r�,LLo.s; ,�.>,w.v,v w, ,m m� 10 SISAIbNV ONINOZ f — Building Department ARplication AUTHORIZATION (Where the Applicant is not the Owner) 1 Pablo Salame residing at 14895 Main Rd. _ (Print property owner's name) (Mailing Address) East Marion, NY 11939 do hereby authorize Steven_Affelt (Agent) to apply on my behalf to the Southold Building Department. (Owner's Signature) Tate) Pablo Salame .._ _..... _ ... ........ (Print Owner's Name) Glenn Goldsmith,President � � Town Hall Annex �, �� �� 54375 Route 26 A.Nicholas Krupski,Vice President P.O. Box 1179 Eric Sepenoski r Southold,New York 11971 Liz Gillooly Telephone(631) 765-1892 Elizabeth Peeples Fax(631) 765-6641 o""r BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD March 16, 2023 James L. Walker Inter-Science Research Associates, Inc. P.O. Box 1201 Southampton, NY 11969-1201 RE: DOMELUCA II, LLC 14895 ROUTE 25, EAST MARION SCTM# 1000-23-1-2.10 Dear Mr. Walker: The following action was taken by the Southold Town Board of Trustees at their Regular Meeting held on Wednesday, March 15, 2023: RESOLVED that the Southold Town Board of Trustees grants a One-Year Extension to Wetland Permit#9863, as issued on April 14, 2021. This is not an approval from any other agency. If you have any questions, please do not hesitate to contact this office. Sincereiy, Glenn Goldsmith President, Board of Trustees GG:dd DATE(MM/DD/YYYY) ACC-)R" CERTIFICATE OF LIABILITY INSURANCE �• 3/10/2023 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(i'es)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 O TACT NAIVE _Rebecca Le 'ItoWakt ...... .. ... Arthur J. Gallagher Risk Management Services, LLC PHONE 9 ° IFA-X -,_� -_87° 83-87 4 30 Century Hill DriveL Suite 200 tass Rebecc PK9y_ i ajg Com � Latham NY 12110 .. ....... INSURERLS AFFORDING COVERAGE _M91 . _,..._,.�.,, .... ..............,,,_..._..., ... INSURER A:Continental Insurance Company ..... _.................. wwwwww35289 INSURED INSURER B Travelers Pro a Casual Co of America 25674 Ron Gibbons Swimming Pools Inc INSURER ��� �mITITITIT 171 Bridge Road wsuRERc Columbia CasualtywCompany 31127 Islandia NY 11749wsURER9: INSURER E INSURER F COVERAGES CERTIFICATE NUMBER:1252020201 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. .-..._.m. .a --._.-_-.-_-..�-. ....... . LIMITS.,,, ..... ILTR ....�.-.,......_r �C}3�SUBR� ......... .....__ „�..�,. .......-POLICY EFF POL9C'X EXP TYPE OF INSURANCE POLICY NUMBER _..IAfIM/ D MWD. Y A X COMMERCIAL GENERAL LIABILITY Y 4034371327 1/1/2023 1/1/2024 EACH OCCURRENCE $1,000000 00,000 ... CLAIMS-MADE OCCUR 5,000 X Contractual Liab MED EXP(Any one person) PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATEmmm $2,000,000 POLICYLOC - -._...... �JECTPRO PRODUCTS OMP/OP AGG $ 2,000,000 Limited PollutionSee Below mmmm OTH;E;R A AUTOMOBILE LIABILITY 4034371344 1/1/2023 1/1/2024 COMBO'EeOSIN'LEL1MIT $1,000000 ..Ca��cmde¢ad7, .._..._.. X ANY AUTO BODILY INJURY(Per person) $ W OWNED SCHEDULEDBODILY INJURY .-..... .,_� .... I Y(PeracGdent $ AUTOS ONLY AUTOS -X NON-OWNEDHIRED AUTOS ONLY X_.. AUOS ONLY d .r�IdanAh�AGF .$ PROPERTY .... .... $ OCCUR ,000,000 A X UMBRELLALIAB X 4034371330 1/1/2023 111/2024 EACH OCCURRENCE $,mm10mm.... EXCESS LIAB CLAIMS-MADE AGGREGATE $10 000 000 DED X RETENTION$ $ ..mm WORKERS COMPENSATION PER OTH AND EMPLOYERS'LIABILITY STATUTE'°' YIN -.... ANYPROPRIETOR/PARTNER/EXECUTIVE F7 N/A _ DENT $ OFFICER/MEMBEREXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ CCI E.L EACH A ..... ......,..�....,_,,,-,.-... ......,,,,,,_, If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ B Lease/RentEQPT QT6606B281201TIL23 1/1/2023 1/1/2024 $150,000 A Installation/Stored Materials 4034371327 1/1/2023 1/1/2024 $25,000 C Professional Liab. 6075534790 1/1/2023 1/1/2024 $1M 0.1$2M A,, $10,000 SIR DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Professional Liability Coverage is Claims Made;Retroactive Date 12/11/2018 Limited.Pollution Liability Coverage-Worksites Endorsement: -Each Limited Pollution Incident Limit:1,000,000 -Limited Pollution Liability Aggregate Limit:$2,000,000 See Attached... 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. 54375 Route 25 - PO Box 1179 AUTHORIZED REPRESENTATIVE Southold, NY 11971 I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD YORK WOrkerS' CERTIFICATE OF INSURANCE COVERAGE STATE Compensation NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW Board PART 1. To be completed by NYS 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 Ron Gibbons Swimming Pools,Inc. (631)851-3000 171 Bridge Road 171 Bridge a Road 1c.Federal Employer Identification Number of Insured Islaor Social Security Number Work Location of Insured (Only required if coverage is specifically 11-2572903 limited to certain locations in New York State,i.e.,a Wrap-Up Policy) 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Metropolitan Life Insurance Company 3b.Policy Number of Entity Listed in Box 1a Town of Southold 219266 54375 Route 25 3c.Policy Effective Period: Southold, NY 11971 January 1,2023 to December 31,2023 4.Policy provides the following benefits: RA. Both disability and Paid Family Leave benefits. ❑ B. Disability benefits only. ❑ C. Paid Family Leave benefits only. 5.Policy covers: RA. 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 described above. Date Signed: March 13 2023 By:iftelb4a J&udUiw (Signature of insurance carrier's authorized representative or NYS licensed insurance agent of that named insurance carrier) Email Address: adpts spu@metlife.com Name and Title: M91issa Rankins State Plan 0 r� Itant 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 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.nv.eov 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 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(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. D13-120.1 (12-21) C CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) �,• 03/10/2023 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). ...__...� Marsh Affinity ......... PRODUCER CONTACT i NAME: ty Marsh Affinity (A/C N*,Exty, 800-743,16130 �.(AdC Nom _.. .n....... a division of Marsh USA Inc. E-MAIL ADDRESS.. ADPTo[alSource@marsh.com PO Box 14404 -- Des Moines,IA 50306-9686 .�.�NSU RER(S)AFFORDING COVERAGE NAIC# .,, - ........... .. ........ INSURER A: New Hampshire Insurance Co. 23841 ......... ........ INSURED INSURERS: ADP TotalSource FL XVII,Inc. INSURER C: 5800 Windward Parkway INSURER D: Alpharetta.GA 30005 "".... ..."" ."." ""'"..."""" ..�� ......... I UCIF: INSURER E: ._.. .__._ ....�.... ... RON GIBBONS SWIMMING POOLS INC INSURER F:. 171 BRIDGE RD Islandia,NY 117490000 ........._. ._.... . . .._..... COVERAGES CERTIFICATE 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 INSR ADDLSUBR FUL10YEPP POLICY EXP LTR TYPEOFINSURANCE INSID WVD POLICY NUMBER (MM/DD/YYYY) (MMIDD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE - ITITIT ITIT$ (CLAIMS-MADEOCCUR IDAhuNrt,GE TO_.CN'TED $ _ PREMISES aoggMU1a21 MED EXP(Any one person) $ _._.. . ...... ........ . PERSONAL 8 ADV INJURY $ CEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ ....... POLICY F__]PRO F—]LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMSNEDSf1*l E-LIMIT $ Ea accident) ANY AUTO BODILY INJURY(Per person) $ AUTOS ONLY AUTOS OWNED SCHEDULED BODILY INJURYaccident) $ (Per_... ITmm,mmm HIRED NON-OWNED PROPERTY DAMAG.E. $ AUTOS ONLY AUTOS ONLY fear 3 'id8Ai).......... ....�...... ......._ $ IEX BRELLA LIABJ '..00CUR EACH OCCURRENCE CESSLIAB '.CLAIMS-MADE AGGREGATE..DED .RETENTIONS • $ - . W TH WORKERS COMPENSATION •X STATUTE ER ANDEMPLOYERS'LIABILITY YIN ANYPRrOPRIETpRiPAR'TNER.MXECUTIVE E..L.EACH ACCIDENT $ Unlimited OFFICERFMEMBER.EXCLUDED? NIA WC 053439004 NY 07/0112022 07/0112023 A Mandatory in NH) Li pc L DISEASE-EA EMPLOYEE $ Unlimited Ef M,descNne under . - $ Ilnlimited DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT ......... DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be atla�ched if more space Is required) All worksite empWoyees working for RAN OBSONS SWIMMING POOLS INC paid under ADP TOTALSOURCE,INC:s payroll,are coveters under the at+*we stated potiay. .�............. ......... ........ ........m.... . - ...._._..,,,...T. ._..........�..�.Y.�.._...._. CERTIFICATE HOLDER CANCELLATION Town of Southold 54375 Route 25 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Southold,NY 11971 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. REPRESENTATIVE AUTHORIZED REPRESE ..�. �� ©'t888 2015 AWOROD)406' RPO ION, Allrl is reserved.ACOtD 25(24161fb8) g The ACORD name and logo are registered marks of ACORD -' ot YORK BMnsat'io CERTIFICATE OF oaki NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured ADP TotalSource FL XVII,Inc. 6318513000 5600 Windward Parkway Alpharetta,GA 30005 1c.NYS Unemployment Insurance Employer RON GIBBONS SWIMMING POOLS INC Registration Number of Insured 45-045108 171 BRIDGE RD Islandia,NY 117490000 1d.Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured(Only required if coverage is speci;lcally limited to certain locations in New York State,i.e., a Wrap-Up Policy) 112572903 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) New Hampshire Insurance Co. Town of Southold-Building Department 3b.Policy Number of Entity Listed in Box"l a" 54375 Main Road WC 053439004 NY Town Hall Annex-P.O.Box 1179 All worksite employees working for RON GIBBONS SWIMMING POOLS INC Southold,NY 11971-0959 paid under ADP TOTALSOURCE,INC's payroll,are covered under the above stated policy. 3c. Policy effective period 07/01/2022 to 07/0112023 3d.The Proprietor,Partners or Executive Officers are ®Included.(Only check box if all partners/officers included) ❑all excluded or certain partners/officers excluded. This certifies that 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 3A 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 Certificate.(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 listed in box 113c",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 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: Michael Price (Print name of aut miz d representative or licensed agent of insurance carrier) Approved by: • 1-1,110-4 16-MAR-2023 (Signature) (Date) Title: CEO North America Telephone Number of authorized representative or licensed agent of insurance carrier: 600-743-6130 Please Note:Only insurance carriers and their licensed agents are authorized to issue Form C-105.2.Insurance brokers are NOT authorized to issue it. C-105.2 (9-17) Certificate Number: www.wcb.ny.gov