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HomeMy WebLinkAbout50006-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#: 50006 Date: 11/8/2023 Permission is hereby granted to: Perm Matthew 360 E 72nd St Apt 131701 New York, NY 10021 To., construct accessory in-ground swimming pool as applied for per ZBA approval. At premises located at: 3200 Camp Mineola Rd, Mattituck SCTM # 473889 Sec/Block/Lot# 123.-5-36.2 Pursuant to application dated 9/13/2023 and approved by the Building Inspector. To expire on 5/9/2025. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO - SWIMMING POOL $50.00 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 Y Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only 36b E C E I V E w PERMIT NO. Building InspectorSEP '13 2023 msi/%/ �! Building Department � r r (i �f /�// %f Town of Southold�r'��r�r/'�/r�;«1%r(,%,�G/�/ %%Ji✓%�/,`�l�f/1/i 1/r / �%/'}///��, '°r r r�r Jr�� ��I�� ����f �IGL Date:. ✓'/JlfON Z /�,�/// r,ra Name ... SCTM# 1000- 2 r ject Address IN Phone 6_ � _� M.mm... .... ... .... Email _. . MailingAddress o , s4q 6a v J ,rn i ;u e✓' r�%�/ / '/// / r/,rrrJ1J}!,nl1i�n"�iJ�li�, f l : ( l f v ... % i�/,,)r Phone#. . w... Email � wt. {� , :, °�� r� ;r� rrr✓,,,,;, ,, �,,:y sir/ r/ _�r ;i �/r r ,/ � iii', r�/iiia /'�p�,/ r;�, y;,;%r' cw r ,,,N,r ,.. a .,.� r . .r.. �✓//l/,1,/�i� /r%r, i/ �//'�//'�// �/'r /� // / � /, /�/ /i� - �1�/ .' r /r'rr // 1 I !e I r��r �>!.,��l. /r✓�,���/�,(/l�/�//�� ����rl �� /l i-�l���ll� ,���l�� � �� e.� Mailing Address; � ,. Phone#. d Email: M77 Name: ELI' f MailingAddress: Phone#: Email: " '�'•� +r✓ , �G✓1•� 00 �0, r ! F1 # I '1 ew Structs ❑Addition ❑Alteration ❑Repair El Estima�d�Cost cProject: p ❑Other 0a Will the lot be re-graded?�es ❑No Will excess fill be removed from premises? Yes t�No 1 PROPERTY INFORMATION Existing use of property: Intended use of property: Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? []Yes Llo IF YES, PROVIDE A COPY. r / rls s d • er� d I sY11 �+ f, d>,` rf�sto��niwate/�yr, ify� 13�X er eading�.'?h,��iy�i „/ 9r#�`��#r/ esigFt:, f�#ass+b'al sree Ile or all, airta � / / -,...,. � ,,,,y „„, r1�1 ...., r „/�.,,;�J.,, f. � r r/,✓/ // ., r /�, ,:r. / //, oo ,�/�//r or/� r/.:: „�. / ���j/ „i,..: J ,/�;.../ ai /,i{ r ,off�/ „/,r./r /r r„I/ i//r%/ri,,//r ri,/%oma//�✓ ��/fir,//�/a r � / ��G % ,. r /�j . irz ae,- Application Submitted R Int me : v G, horized A ent []Owner �,V4”� Ou Signature of Applicant: Date: �lr)23 STATE OF NEW YORK) SS° COUNTY OF ) jlh 4v being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract) above named, (S)he is the GN ' (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 applicat, to the best tai”his/her knowledge and belief;and that the work will be performed in the manner xf I l ARRA, eNTO ew ith• NO.01-P16090455 Sworn before me this QUALIFIED IN SUFFOLK COUNTY MY COMMISSION EXPIRES APRIL-14,202-7> 4,2027 Sday of v.r �- 202, Notary p 'lic PROPERTY OWNER AUTHORIZATION (Where the applicant is not the owner) ,�'" 'r residing at YN 1 Ii7 e!// ' � do hereby authorize Yrl � a ''p �'1 to apply on my behalf to the Town of Southold Building Department for approval as described herein. GREGORY PINTO .raw. NOTA 0:i'PUBLiC,STATE OF NEW YORK " — 1,40.01-P!6090455 /L. Owner's Signatur QUALIFIED IN SUFFOLK COUNIT'ti% Date ;�-,Y COMMISSION EXPIRES APRIL i4,20 Z 7 Print Owners Name 2 CONSENT TO INSPECTION 2G fr, the undersigned, do(es)hereby state: Owner(s)Na e(s) That the undersigned is (are) v�.owner ) of�the arerniges�the Town o (� ) Southold located at which is shown and designated on the Suf lk County Tax Map as District 1000, Section , Block. Lot .Z That the undersigned(hag) (have) filed, or cause to be filed, an application in the Southold Town Building Inspector's Office for the following: V...fw,w,.N cr ti That the undersigned do(es)hereby give consent to the Building Inspectors of the, Town of Southold to enter upon the above described property,including any and all buildings located thereon,to conduct such inspections as they may deem necessary with respect to the aforesaid application, including inspections to determine that said premises comply with all of the laws, ordinances, rules and regulations of the Town of Southold. The undersigned, in consenting to such inspections, do(es) so with the knowledge and understanding that any information obtained in the conduct of such inspections may be used in subsequent prosecutions for violations of the laws, ordinances,rules or regulations of the Town of Southold. Dated: a (Signtur°e GREGORY PINTO (Print Name) NOTARY PUBLIC,STATE OF NEW YORK QUALIFIED IN:EX:P;I;R;ES FOIwIC I„��«IMY COMMISSION (Signature) NO.01-P16090455 (Print Name) Building Department ent A licaation AUTHORIZATION (Where the Applicant is not the Owner) I, �►l.•-- e t r residing at; 2VU (Print property owner's name) (Mailing Addres)) G Ic do hereby authorize ) e yt ono•�� (Agent) u i ►.. to apply on my behalf to the Southold Building Department. " ' (Owner's Signature) (Date) (Print Owner's Name) GREGORY PINTO NOTARY PUBLIC,STATE OF NEW YORK. NO.01-PI6090455 QUALIFIED IN SUFFOLK CX( Uljlr( MY COMMISSION EXPIRAPRIL.. 14,2(1 2— 0 BOARD MEMBERS Southold Town Hall Leslie Kanes Weisman,Chairperson ��, 53095 Main Road•P.O.Box 1179 Patricia Acampora �' , Southold,NY 11971-0959 Eric Dantes Qffice Location: Robert LehnertJr. Town Annex/First Floor 54375 Main Road(at�6oungs Avenue) Nicholas Planamento c �"�`° So 6 MO pow, ��� http://southoldtownny.gov + # _.p� ZONING BOARD OF APPEALS JDL 2 4 2023 TOWN OF SOUTHOLD Tel. (631)765-1809 Southold' own Clerk FINDINGS,DELIBERATIONS AND DETERMINATION MEETING OF JULY 20,2023 ZBA FILE: 7798 NAME OF APPLICANT: Matthew&Jill Perry PROPERTY LOCATION: 3200 Camp Mineola Road,Mattituck,NY SCTMNo. 1000-123-5-36.2 SE RA DETER1MATION: The Zoning Board of Appeals has visited the property under consideration in this application and determines that this review falls under the Type II category of the State's List of Actions, without further steps under SEQRA. FOLK COC1tTY.AD l.S E: This application was referred as required under the Suffolk County Administrative Code Sections A 14-14 to 23,and the Suffolk County Department of Planning issued its reply dated April 3,2023 stating that this application is considered a matter for local determination as there appears to be no significant county-wide or inter-community impact. LWRP DETERMINATION,: The relief, permit, or interpretation requested in this application is listed under the Minor Actions exempt list and is not subject to review under Chapter 268. PROPERTY FACTS/DESCRIPTION: The subject property is a 13, 834 sf nonconforming lot located in an R-40 Zoning District. The property has a road frontage along Camp Mineola Road of 135.45 feet then turns west for 100.17 feet along Allen Drive,then turns south for 141.23 feet along Fay Court before returning 100.00 feet back to Camp Mineola Road. The property is improved with a two-story frame dwelling. The property has three front yards, although two of them are from paper roads, thereby giving the subject lot a very small rear yard all as shown on survey prepared by Kenneth M. Woychuck,L.S., last revised October 14,2022. mm13SIS OF P LIC1C!N: Request for Variances from Article III, Section 280-15; Article XXIII, Section 280- 124; and the Building Inspector's January 18, 2023,Notice of Disapproval based on an application for a permit to construct an accessory in-ground swimming pool, at; 1) located in other than the code required rear yard; 2) more than the code permitted maximum lot coverage of 20%;located at 3200 Camp Mineola Road,Mattituck,NY. SCTM No. 1000-123-5-36.2. R13L EF RE 1 T E : The applicant requests variances for the following: 1) Locate an accessory in-ground swimming pool in the side yard where a rear yard location is required. 2) The proposed swimming pool would increase the lot coverage to 25.2%where a maximum of 20%is required. ADDI 1NEQ AT1ON: As per testimony from the applicant's agent, the property has 3 front yards, although two of them abut paper roads. The lot coverage was previously given alternative variance relief of 24.3% in ZBA#6176,dated August 25,2008. The updated survey lists the existing house,deck and outdoor shower already measuring of 24.7% lot coverage. The applicant is also proposing to remove a portion of the existing deck and the k Page 2,July 20,2023 #7798,Perry SCTM No. 1000-123-5-36.2 outdoor shower in order to construct thein-ground swimming pool and reduce the lot coverage. The applicant's representative presented several prior comparable'variances granted in the neighborhood for excessive lot coverage and accessory swimming pools located in the side yard. These determinations have been included as part of the record. The applicant confirmed that the location of the mechanicals and the drywell will be placed on an updated survey which was received by the Board on July 14, 2023. FINDINGS OF FACT/REASONS FOR BOARD ACTION: The Zoning Board of Appeals held a public hearing on this application on July 6,2023 at which time written and oral evidence were presented. Based upon all testimony,documentation,personal inspection of the property and surrounding neighborhood,and other evidence,the Zoning Board finds the following facts to be true and relevant and makes the following findings: 1. Town Law 267- 3 J Grant of the variances will not produce an undesirable change in the character of the neighborhood or a detriment to nearby properties. The immediate area consists of approximately five improved parcels within the block, all of which have more than one front yard, many having received variance relief. The subject property was previously granted variance relief for allowable lot coverage of 24.3%.However,the applicant is removing a portion of the existing deck to be replaced with an on-grade accessory swimming pool. Therefore, no undesirable change to the character of the neighborhood will occur. 2. Towyn Law 267-b 3 b 2 , The benefit sought by the applicant cannot be achieved by some method feasible for the applicant to pursue,other than an area variance. Due to the fact that the existing residence comprises 20%of the lot coverage,and the property was already given prior variance relief for excessive lot coverage, any addition to the residence or installation of accessory structures would require variance relief. Also, due to the lot having three front yards,any accessory structure would require relief from having them in the required rear yard. 3. Town Law 267-b ,3 Ia 3 . The variances granted herein are mathematically substantial: The proposed side yard location represents a 100% relief from the code.The proposed lot coverage represents an approximately 26% relief from the code. However,the location of the proposed pool in the side yard is due to the fact that the property has three front yards. The technical side yard where the pool is proposed to be located is the architectural rear yard of the dwelling and fronts a paper road that is not paved and ism well screened from view by existing evergreen Iandscaping. The proposed lot coverage has already been expanded in previous variance relief,but the homeowner is removing much of the existing deck and an outdoor shower to bring the lot coverage more into compliance with the code. 4. Town Law 267-b 3 b 4 No evidence has been submitted to suggest that a variance in this residential community will have an adverse impact on the physical or environmental conditions in the neighborhood. The applicant must comply with Chapter 236 of the Town's Storm Water Management Code and conditions of this board. 5. Town Law 26 "-b 3 b The.difficulty has been self-created. The applicant purchased the parcel after the Zoning Code was in effect and it is presumed that the applicant had actual or constructive knowledge of the limitations on the use of the parcel under the Zoning Code in effect prior to or at the time of purchase. 6. Town Law 4267-b. Grant of the requested relief is the minimum action necessary and adequate to enable the applicant to enjoy the benefit of an accessory in-ground swimming pool while preserving and protecting the character of the neighborhood and the health, safety and welfare of the community. RESOLUTION OF THE BOARD:In considering all of the above factors and applying the balancing test under New York Town Law 267-B,motion was offered by Member Lehnert,seconded by Member Acampora,and duly carried, to Page 3,July 20,2023 #7798,Perry SCTM No. 1000-123-5-36.2 n GRANT the variances as applied for,and shown on the survey prepared by Kenneth M Woychuk,Land Surveyor last revised July 13,2023 SUBJECT TO THE FOLLOWING CONDITIONS: 1. Pool pump equipment/mechanicals must be located a minimum of 20 feet from any property line or be contained in a shed type enclosure with a lot line set back that is in conformance with the bulk schedule for accessory structures 2. Drywell for in-ground swimming pool de-watering shall be installed. This approval shall not be deemed effective until the required conditions have been met.At the discretion of the Board of Appeals,failure to comply with the above conditions may render this decision null and void That the above conditions be written into the Building Inspector's Certificate of Occupancy, when issued The Board reserves the right to substitute a similar design that is de minimis in nature for an alteration that does not increase the degree of nonconformity. IMPORTANT LIMITS ON THE APPROVAUS1 GRANTED HEREIN Please Read Careful] Any deviation from the survey,site plan and/or architectural drawings cited in this decision, or work exceeding the scope of the relef granted herein, will result in delays and/or a possible denial by the Building Department of a bull4ing permit and/or the issuance of a Stop Work Order, and may require a new application and public hearing before the Zoning Board of Appeals. Any deviation from the variance(s)granted herein as shown on the architectural drawings,site plan and/or survey cited above,such as alterations, extensions, demolitions, or demolitions exceeding the scope of the relief granted herein, are not authorized under this application when involving nonconformities under the zoning code. This action does not authorize or condone any current or future use,setback or other feature of the subject property that may violate the Zoning Code,other than such uses,setbacks and other features as are expressly addressed in this action. TIME LEMS ON THIS APPROVAL: Pursuant to Chapter 280-146(B)of the Code of the Town of Southold any variance granted by the Board of Appeals shall become null and void where a Certificate of Occupancy has not been procured,and/or a subdivision map has not been filed with the Suffolk County Clerk,within three(3)years from the date such variance was granted. The Board of Appeals may,upon. written request prior to the date of expiration,grant an extension not to exceed three(3)consecutive one(1) year terms.IT IS THE PROPERTY OWNER'S RESPONSIBILITY TO ENSURE COMPLIANCE WITH THE CODE RE OUMED TIME FRAME DESCRIBED HEREIN.Failure to comply in a timely manner may result in the denial by the Building Department of a Certificate of Occupancy,nullify the approved variance relief,and require a new variance application with public hearing before the Board of Appeals Vote o the Board: Ayes:Members Weisman(Chairperson),Dantes,Planamento,Acampora and Lehnert(5-0). G eshe leans Weisman, hairperson Approved for filing � /oy /2023 s S.C.T.M.NO. DISTRICT: 1000 SECTION:123 BLOCK:5 LOT(S):36.2 *MED JUL 14 2023 ZOWNGBOAAD01"APPOLt -7 ALLEN DRIVE PIPE 30' R.O.W, (NOT OPEN) _ FD U.PN 88"29'30" E wNa . 100.17 NYT 26 POOL,WAVE WATER wow 10.0' WD.L MIX EQP. Ra cri BR74*,y. aw° Irl V-L W 10.2 _ I TO BE REMOVED 7.0 Z DECK " 3 w 0 21.0' 3 S, IT d U d I I raTr' r +r o � NFILINC hal 110 2OM 0+1 ' pq 1.1.1" 5 OT 35,0' ...._.,... 0"+ w"ROOF OVER �? CONC./SLATE PORCH 11 ',w 26.W O o 0 = c % 0- Q+ I * O I M z � I rQJ �.. kkE;Dk,E..CE'NERAL4.Y b+`0111W CYF q:IN'E S 85-11,00" w 100.00 FIN L_ AP' LAND N/F OF DUNN RE IE ED BY ZBA DEC ION# —1-7q EXISTING LOT COVERAGE DATED; e..e7 i' 4„& ® DWELLING W/COVERED PORCH: 2764 S.F. REAR DECK: 594 S.F. OUTDOOR SHA ER. 56 S.F. ADD POOL EQP./DRYWELL 07-13-23 �...„iHT...........L 3414 S.F. or 24.78 UPDATE SURVEY 10-14-22 PROPOSED LOT COVERAGE UPDATE SURVEY 06-17-20 DWELLING W/COVERIED PORCH: 2764 S.F. RW DECK: 207 S.F. FIRM MAP�l36103C0482H SWIMMING POOL: 512 S.F. 71 SUBJECT COVENANT TOTAL: 3483 S om THE WATER SUPPLY, WELL$DRYWELLS AND CESSPOOL AND RESTRICTIONS AS STATED LOCA77ONS SHOWN ARE FROM FIELD OBSERVA7701VS LIBER 12196 PG 14 AND OR DATA OBTAINED FROM DINERS AREA: 13,834 S.F. OR 0.32 ACRES ELEVATION DATUM.• UIVAUIT87ED A1.7ERA 7NGN'C4W A0D17TONP TCI 7HT5 SUBVE"Y 15 A kTC7LA.T7ON 0d"',"M'.""'770N'7e^18.a OF'1ktti.E"NA£4Y''MOp"d1C S7;k"dE'd'DtlJ'L"47tIP d,�41ryC COd41L'S CE' �i*TPMS SGki'E`N° MAF"NDT B'E°ARTND Bir L.ANO svRrrk°;m's k".MBO.SS"O BE& SHALL NO T BE TO BE A 'VAUD 7RUE COPY, OUARAN'TEES WOVCA'TED T4E•T'tECNV SHALC.SAI'M ONLY TO T7WF prR.SON FOR W jCM W SUR'M:°Y TS PRlEPARFD ANDOWW HIS BEHALF TO 7HE RXE COMPANY GOWONMF9TA4.AGENCY AND IXUDING TNS'nnw)ftON LASTED H&REONV AND 70 TRE"ASSI'MEES OF 7IWF 4ENLITNG 7NS'TNT7,ITA", OUARANITE"S ARE NOT TRANV E'RAStE, TT'7£OFFSETS OR DWENSTONS VQWN X"ON FROM 771E PRDPER"'TY LNNES FO D6E STRCA'."n)RES ARE MR A SPt4iFIC PUIRPO4Ei' AAO USE PABEREFMTWE rK7'AW NOT"'MWTE°NOJ'a'TO MONUA(FBIT THE PPa0FR'T'Y UNT"S OR TO GUIDE INE'ERECR W YAC FENCE% ADOd`I?ONp'AL S7R1YON)'RES 074^AND 0I'HEER IUPRO MYr:TAENTS EA XYE 75 AND AR SUBSURFACE"S7°R"UOAR,IR-5 RFCOTOTED OR 4MFC'Cx,,`W0 AAE NOT GUARANTEED 4 MLESS PHYSICALLY ECWT •NT 004 DO...'PRE0SES AT ME 71ME OF SURI4°Y SURVEY OF: DESCRIBED PROPERTY CERTIFIED TO:MATTHEW PERRY; JILL PERRY„ MAP OF: ITLE BRIDGE ABSTRACT; STEWART TINSURANCE COMPANY; FILED: ....... .............®. - ...............,,... SITUATED Ar.MATTITUCK ___w. _........_........................... TOWN OF:SOUTHOLD ]KENNETH-M-W C3 r,, '['�4N'p S y G, P1d,C SUFFOLK COUNTY, NEW YORK Professional Lend Surveying and Design yr Yr P.O. Boa 153 AqueLogue, New York 11931 FILE 111 25-47 SCALE: 1"=20' DATE.APRIL 21,2005 - +# PHONE(e31)2e8-16ee FAX(est) 29e-i6ee N.Y.S. LISC.NO. 050882 F z _ F , 3 = Suffolk County Department of Labor, Licensing & Consumer sirs VETERANS MEMORIAL HIGHWAY * HAUPPAUGE,NEW YORK 11788 � DATE ISSUED: 3/1/1977 No. 3585-H t 9 SUFFOLK COUNTY a� o e Improvement Contractor License R- s� A This is to certify that KENNETH J BARTHMAN ° doing business as DUNRITE MANUFACTURING CORP having furnished the requirements set forth in accordance with and subject to the provisions of applicable laws,rules and regulations of the County of Suffolk, State of New York is hereby licensed to conduct business as a HOME t IMPROVEMENT CONTRACTOR, in the County of Suffolk. 01A 'M License Category r � Pools/Spas NOT VALID WITHOUT Additional Businesses Other DEPARTMENTAL SEAL AND A CURRENT DTJNRITE POOLS CONSUMER AFFAIRS i ID CARD ' Suffolk County Dept.of �-��-� � � Labor,Licensing&Consumer Affairs Commissioner I �y HOME IMPROVEMENT LICENSE \£ . 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'MOI38 S310110d 31-11 AS a3a2d033V 39VU21A00 31-11 M311V 110 ON31X3 `aN3WV A13AI1VEM NO A19AUMM133V ION S30a 31V01d111130 SIH! 'N30-10H 31V013112l30 31-11 NOdn SIHJRJ ON SN33N00 aNV AINO NOIIVWMO=INI 30 N311VW V SV a3nSS1 SI 31V01311a30 SIH! £zoz/0£f£0 (AAAA/OOIWW)31tla 33NvmnSN1 AIIII13` II =10 31V31=1I1b30 �y nuC..JF n " Workers' CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE �aR1 TAT Compensation COVERAGE Board la. Legal Name&Address of Insured(Use street address only) 1 b. Business Telephone Number of Insured 516-543-1616 Dunrite Manufacturing Corp 3510 Veterans Memorial Highway 1c. NYS Unemployment Insurance Employer Bohemia, NY 11716 Registration Number of Insured Work Location of Insured (Only required if coverage is specifically limited to certain locations in New York State,i.e.,a 1d. Federal Employer Identification Number of Insured Wrap-Up Policy) or Social Security Number 112245133 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage (Entity Being Listed as the Certificate Holder) AmTrust Insurance Company of Kansas Inc Town of Southold 3b. Policy Number of entity listed in box"1 a" 530950 Route 25 KWC1223367 Pa Box 1179 Southold, NY 11971 3c. Policy effective period 10/20/2022 to 10/20/2023 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 "1a" 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 will also notify the above certificate holder 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 "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 Workers'Compensation contract of insurance only while the underlying policy is in effect. Please Note: Upon the 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: Kevin McDonough.... IT,,,, (Print name of authorized representative or licensed agent of insurance carrier) Approved by: Ail, 10119!2.022 (Signature) (Date) Title: President of Walter Rose Agency,Inc Telephone Number of authorized representative or licensed agent of insurance carrier: 845-783-2555 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) www.wcb.state_ny.us �YO w�rl4+�r�• CERTIFICATE OF INSURANCE COVERAGE Cxzrnpensation 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 1a. Legal Name&Address of Insured(use street address only) ib. Business Telephone Number of Insured DUNRITE MANUFACTURING CORP 3510 VETERANS MEML HGHWY BOHEMIA,NY 11716 1c. Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured(Only required ifcoverage is spec.Wcally limited to certain locations in New York State,i.e.,Wrap-Up Policy) 112245133 2.Name and Address of Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) ShelterPolnt Life Insurance Company Town of Southold Building Department 3b. Policy Number of Entity Listed in Box"fa' 530950 Route 25 DBL593730 PO Box 1179 3c. Policy effective period Southold, NY 11971 01/01/2022 to 12/31/2023 4. Policy provides the following benefits, tJ A Both disability and paid family leave benefits. B. Disability benefits only. C. Paid family leave benefits only. 5. Policy covers: © A All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law, B.Only the following class or classes of 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 1202022 By y (5ignature of insurance carrier's authorized-epresentative or NYS Licensed Insurance Agent of that irsurance 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 413,4C or 56 have been checkedl 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 (S:gnatu-e of Authorized NYS Workers'Compeisation Board Employee) Telephone Number Name and Title Please Note:Oniy insurance carriers licensed to write NYS disability and paid family leave benefits insurance policies and NYS licensed insurance agents of those insurance carders are authorized to issue Form DB-120.1.Insurance brokers are NOT authorized to issue this form. 1313-120.1 (12-21) 1111111° °°1°�!!°11°1°111°11°� 1°111111