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HomeMy WebLinkAbout51065-Z TOWN OF SOUTHOLD stxr BUILDING DEPARTMENT „A 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#: 51065 Date: 8/13/2024 Permission is hereby granted to: Calvo, Agustin 812 Grand St Apt 219 Hoboken,NJ 07030 To: Install new pool liner, pool equipment and fence for an existing in ground swimming pool as applied for. At premises located at: 1820 Wells Ave, Southold SCTM # 473889 Sec/Block/Lot# 70.-3-20 Pursuant to application dated 6/21/2024 and approved by the Building Inspector. To expire on 2/12/2026. Fees: CO - SWIMMING POOL $100.00 SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $125.00 Total: $225.00 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 l�tt s://www.souwtholdtgw . oy ,, Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only PERMIT NO. S Building Inspector. � UPS 2 1 20 24 BUILDUMDE". TOWN X SOUT1101 Date:June 19, 2024 Name.Melissa & Agustin Romo Calvo SUM#1000 473889 70 3 20 o oj Prect Address:1820 Wells Avenue Southold, NY 11971 m ��... .w. .. .�.., a._��_w.. ....,...e.�. .w� ��.. Phone 238#:201-401-6 all melissao@mail. .. �.,.�m....n�..._ �..._" J Em trom com._w._. M...._a_il.l_n� A....d.md,r...ess 182 Wells Avenue Southold, NY 11971 ..... . .__ .mm.m..�. �.� ._� .. �w...... Name:Melissa Romo Mailing Address:1820 Wells Avenue SoutholowNY 11971 Phone#:201-401-6238 Email:melissaromoftmail corn Name e Need w. ..Sweeney°� Pool Service . Nick Acevedo �. �.� �.....m..w ...��.m._..,.u." �. __...mmm�.,,,m..W .......,� _...�. ...m..,.,..wmm__��....,...µ _. MailingAddress k NY 11741 1740 Chinch St, Holbroo .�...� . PPhone# 631 431 0498 Email s�reeneyspoolsvn@9mall corn �...w._...... , � �.- .m",.�.� � � � ,.�-__ _ �.," � �.a s�� I r Name: .... . ...m.r��Sweeney's.._PooL..Servicemm �.NickP Acevedo 40 Church St Holbrook, NY 11741 Mailing Address17 _. ...w..�... ..��,.,...�w�_. .. a. Phone#: 631 431-0498 Email sreenewys000lsvc@,gmail corn US ❑New Structure ❑Addition RAlteration ❑Repair ElDemoiition Estimated Cost of Project: ❑Oth p_grpgke Pc44c $25 420.00 removed from premises? ❑Yes RNo Will the lot be re-graded? ❑Yes RNo � W'NI excess fill be +- �,op 1 MENEM Existing u 11 se of property In Intended use of property 11 . � rw L I.ng r .0 d t,Zone or .. ... use district in which remises is situated �. this property?c❑Yes I�No and YES, PROVIDE A COPY. p Y respect to ent�a w_a Austin Romo Calvo Application$u��m�ttt d B rint name � � � � � � ed Agent BOwner Signature of Applicant: Date: 6/21/2024 STATE OF NEW YORK) SS:/ COUNTYOF �b�l0 CAL U O being duly sworn,deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)he is the '\A 2 a— (Contractor,Agent,Corporate Officer, etc.) of said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this application;that all statements contained in this application are true to the best of his/her knowledge and belief;and that the work will be performed in the manner set forth in the application file therewith. Sworn before me this day of U Ulf- 20 NOTARY PUBLIC,STATE OF NEW YORK Registration No.02SA6407223 PROPERTY'kT OWNER AUTHOR I " TI lified in Suffolk County (Where the applicant is not the o o m�sron Sxpzres 05/16120 I, residing at do hereby authorize to apply on my behalf to the Town of Southold Building Department for approval as described herein. Owner's Signature Date Print Owner's Name 2 BUILDING DEPARTMENT-Electrical Inspector TOWN OF SOUTHOLD Town Hall Annex- 54375 Main Road - PO Box 1179 Southold!New York 11971-0959 Telephone (531)755-1802 - FAX (631)755-950 r APPLLQ6IIQbIEOgLgQIB1966,'NgElEgIlM. ELECTRICIAN INFORMATION (Aai imenration Required) Date: P 21 Company Name: - JVC . El cian's Name: License No.: V- Elec. small: , eat Elec. Phone No: - request An small copy of rtificafe of Compliance Else.Address.: JOB SITE INFORMATION (All Information Required) Name: I u 1k. &114110 Address: Cros s Street: Phone No.: BIdg.Permit#: small: Tax Ma District: 1000 Section: D Block: Lot: 19, 0 BRIEF DESCRIPTION OF CORK, INCLUDE SiD1JA (Please Print Clearly): �pv L w( 4( Id Scluare oosl e: Circle All That AnPly: Is job ready for inspection?: YES❑NO []Rough In ❑ Final Do you need a Temp Certificate?: E, YES❑NO Issued On Temp Information: (All Information required) Service Size71 Ph❑3 Ph Size: A #Meters . Old Meter# ❑New Service❑Fire Reconnect❑Flood Reconnect❑Service Reconnect❑Underground ElOverheadi Unde rownd Laterals 1 H Frame F1 Pole Work done on Service? Y N Additional I t rm ation: " WOE CERTIFICATE OF INSURANCE COVERAGE ,�, ��,��e all�ort i 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 la.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured DRAGONFLY LANDSCAPE DESIGN LTD 159 OLD COUNTRY RD SPEONK,NY 11972 1c.Federal Employer Identification Number of.insured or Social Security Work Location of Insured(Only required if coverage is specifically Number limited to certain locations in New York State,i.e.,Wrap-Up Policy) 273303623 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY TOWN OF SOUTHOLD TOWN HALL ANNEX 54375 ROUTE 25 3b.Policy Number of Entity Listed in Box la SOUTHOLD,NY 11971 LMY634763001 3c.Polity effective period 07-01-2023 to 06-30-2024 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: ❑X A.All of the employers employees eligible under the NYS Disability and Paid Family Leave Benefits Law. ❑ B.Only the following class or classes of employers employees: Under penalty of perjury,1 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 06-24-2024 B (Slgna urs of Insurance carriers authorised representative or NYS licensed Insurance agent of Viet Insurance carrier) Telephone Number 212 50-8074 Name and Title: ELIZABETH TI,LLO—ASSISTANT DIRECTOR STATUTORY SERVICES 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.Mall 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 emalled to PAUQwcb.ny.gov or It can be mailed for completion to the Workers'Compensation Board,Plans Acceptance Unit,PO Box 5200,Binghamton,NY 13902-5200. PART 2.To be completed by the NYS Workers'Compensation Board(Only if Box 4B,4C or 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 compiled 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 Authorised NYS Workers'Compensstlon Board Employes) Telephone Number Name and Title Planes,Note,Only insurance carriers licensed to write NYS disability and Paid Family leave benefrts 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. DATE(INM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE o612412024 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 certHicote holder Is an ADDITIONAL INSURED,the pollcy(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 ri hts to the certificate holder In lieu of such endorsement s). PRODUCER TURFKff HAW, John Micena JOHN MICENA BONE tale 631-288-4454 631m-288 8039mmmmmmm� PO BOX 777 x John.MicenaWmedcan-NabonaLca n ........ INSURER{SAFFDRDING COVERAGE NAIL/ EAST QUOGUE NY 11942 INSURERA: FARM FAMILY CASUALTY INSURANCE CO . .... ........... INSURED INSURER B: _.. ..._........................................................................................... .... DRAGONFLY LANDSCAPE DESIGN LTD INSURERC: �...._._..-... _............................................ PO BOX 974 INSURER D .................-......._._. INSURER E: WESTHAMPTON BEACH NY 11978 INSURERF: 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. LR ........................................ T TYPE OF INSURANCE... ....I tiL .. ................. ... .. Y Y,. POLICY NUMBER -. M wD1 �P LIMITS '...... A X COMMERCIAL GENERAL LIABILITY 3101 X3389 4124/24 4/24/25 EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR $ 100,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1.000.000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE_.....................__......www .. $ 2.000,000 JECT LOCPOUCY�PRO COMP/oP AGG $ 2.000.000# m OTHER: $ A AUTOMOBILELIABILnY 3152C6973 9/3123 9/3/24 COMBINED SINGLE LIMIT $ 1,000,000 m ANY AUTO BODILY INJURY(Per person) $ ............... .. OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY ,,,. AUTOS * HIRED NON-OWNED PR OPERTY biiMA mm� $ AUTOS ONLY AUTOS ONLY S A uMBRELLA L AB X OCCUR 3101 E2435 4124124 4124/25 EACH OCCURRENCE S 1,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ ....... ................. ...... _--........-.....--.-. DED RETENTION$ $ WORMERS COMPENSATION PER AND EMPLOYERS'LIABILI Y Y/N STATUTE16 ......... _ ANYPROPRIETOR/PARTNERIEXECUTIVE E.L.EACH ACCIDENT $ OFFICERIMEMBEREXCLUDED7 El NIA (Mandatory In NH) EE $ E.L.DISEASE..EA EMPLOYEE N describe under OMAPTM OF OPERATIONS bal. E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Ramulm Schedule,may be attached If more space In required) CERTIFICATE HOLDER CANCELLATION TOWN OF SOUTHOLD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN HALL ANNEX THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 54375 ROUTE 25 ACCORDANCE WITH THE POLICY PROVISIONS. SOUTHOLD, NY 11971 AUTHORIZEDREPREBENrATIVE 01988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD L:� Worker ' CERTIFICATE OF INSURANCE COVERAGE r%I�cp�ll" IC�Im nsationi under the NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW ART 1.To be completed by Disability and Paid Family Leave Benefits Carrier or Licensed Insurance Agent of that Carrier 1a.Legal Name 6 Address of Insured(u_.a.et.ddres)any) t b.Business Telephone Number of Insured DRAGONFLY LANDSCAPE DESIGN LTD 159 OLD COUNTRY RD 631-288-8158 1 c.Federal Employer Identification Number of Insured or Social Security SPEONK NY 11972 Number Work Location of Insured 273303623 (Only requlred If coverWe Is ap.cdkAffy llmlfed to certain locations In New York SM.,Le.,Nhap-up Policy) Z Name and Address of Entity Requesting Proof of 3a Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY TOWN OF SOUTHOLD 54375 ROUTE 25 3b Policy Number of Entity Listed in Box"I a" SOUTHOLD,NY 11971 LNY-634763 c Policy effective period 07/01/2024 to 06/30/2025 4.Policy provides the following benefits: M A-Both disability and paid family leave benefits. ❑B.Disability benefits only. ❑C.Paid family leave benefits only. 15.Policy covers: p 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 employers employees: Under penalty of perjury,I certify that 1 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 06/24/2024 f Z e4i n ri 7e-&o" (Signature of Insurance carder'S authorized representative or NYS Licensed Inaurence Agent of that Insurance carrier) Telephone Number (212)553-8074 Name and Title:Elizabeth Tello—Assistant Director,Statutory 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 413,4C 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 5B 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 Si ned B (Signature of Authorized NYS Workers'Compenaatlon Board Erryloyee) Te one Number Name and Title Please Note:Only Insurance carriers licensed to wife 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(9-17) 11111F rRilim,01 120»1 09- 7 IH r 1 "Tzwm CERTIFICATE OF LIABILITY INSURANCE 6� THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THIS CERTIFICATE HOLDER. THI.R CERTIFICATE DUES NOT AFRRtAATIVELY OR NEGATIVELY AMEND. EXTEND OR ALTER THE COVERAGE. AFFORDED BY THE POLICES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT COWTITUTE A CONTRACT BETWEEN THE ISSUING INSURE'R(S, AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. NAPORTANT: If the antiflaft lhloEdtrr G an ADDITIONAL INSURED,the MI N)mog have ADDITIONAL INSURED provisibm or I endorsed. If SUBROGATION 18S WAIVED,�sulysct to the terns and"04 or of tha policy,drtain polities may wire,an endorsement A meant on this cor"flads do"no AlfttoRC��Mllwu�r � ; In V , AlAwi NMI DKM insurance Fu Drive Sine Inc.uran�Agency Hauppauge,NY 1178$ �w� b� hnw'e��i� I sI saerm :lu a CONTINENTIAL CASUALTY COMPANY 20443 . IM5t1R£D If SURER B t SWEENEY'S POOL SERVICE ING. to 1740 CHURCH STREET n.rvELTERTI �Ifti �" u HOLBROOK, NY 11741 ,. COVERAGES CERTIFICATE NUMBER,. VISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSUI�NCE i;.*I"EO BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POI.I Y PERIOD INDICATED. NOTWITHSTANDING ANY REQUTAeMENT',TERN OR CONDITION OF�ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE IN'SUIRANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, ._ �EXCLUSIONS AND CONDITIONSOF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIM_W. T1f➢lt W S AL LIABUTY Y Y 11=2025, EACHOCCURRENCE s 1,000,� CLAIMS-MADE ®OCCUR � f 1�000 Dou [ ,.. CONTRACTUALLIABILITY PEASONAL P �.. a w�oExP s 10�.1t?Il L A GATE N GENERA G6RE GEhr6,AGAPEGA�LIMIT APPLIES PER. Ir^ N POLICY' JE LOC PRODUCTS CCtItI'dOP AGG Ort'rHER. I �I i E L1AlIBJTY 5619571, 1lIbB=24 11OB12II26 1��?i3�,OtI4 ANY AUTO, Y Y BODILY INJURY(P4W f El OWNED SCHEDULED ULED BODILY INJURY(PM ) S 4 AUTOS ONLY AUTO tplRR:r� �Y�'wiku � f A TOS ONLY .._ AUTOS ONLY � s mP x UMBRELLA UAB x OCCUR Y Ft1CHOCCURRENCE f 4w000ka� 70 6067650 1/0812024 11II$1a 0 5 __ _._ A EXCEL L r< nras rAOE INCLUDES AUTOMOBILE AaN .o, _ _ 3_ , �=EXCESS .e .. _. , .,. DED X RETENT10N s AND IIH 88'19572 � R:OMPUSATION AIRY �I ECU" 'YIN MIA w 1 2 1� S E E"C ACCIDENT S u C WON*"InMAN) N Y E L DISEA5£ EA EMPLOYE Low'=I Y(ramef. uldrr ..�_.._ .. DESGRIP nON OF OPERATIONS beWw E.L DW-ASE-POLICY LIMIT 3 Contractor's Tools 170M77104, IAW2024 IAW026 r100: DEBCCRIgI'TMM OF Oft 'r TKM I LOCATIONS I VOWUS(ACED"M,**#0oW ftwft SobOBIBI, Do##M*od it Mw*one b ; Cedfficate Holder is inciuded as additional insured, 15.,E Irrr, n NR rI sl ari De givers hr tNle Liransig Raview Board I CERTI "TE HOLDS G ELICATION Town Hall AWKILD ANIIY OF THE ABOVE MCRISED POMMS Oil CANCELLED 53095 Route 25 TNIE "PMATION DATE THER NOTICE WILL BE, DEL Lam' PO®©X Route AC WITHTlh POLICY & Southold NY 11971 AU RTATIVe 0 1 900201 5 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo me registered marks of ACORD 4fflhWorkerliir CERTIFICATE OF P OAS000" E NYS WORKERS COMPENSATION INSURANCE COVERAGE: 1.a.Legal fame&Address of Insured(use,street address only) 1b.,Bgsinesa Tele a Nurnberof losured SWEENEYS POOL SERVICE INC. 631-431-0498' 1740 CHURCH STREET HOLBROOK,NY 11741 1 c. NYS Unemployment Insurance Employer Registration Number of Insured Work Location of insured(flniy required if coverage is rcaf�+amiled to 1 d.Federal Employer Identification Number of Insured or Social Security curtain locations in New Yorir stare,i.e.,a w hopup Policy) Number 411-3890168 2. Name and Address of Entity Requesting Proof of a 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) UTICA SPECIALTY TUSK INS Cd Town Hall 53095 Route 25 3b.Policy Number of Entity Listed in Box"1 a" P.O.Box 1179 5619572 SQuttmold,NY 11971 , 3c.Policy,effective,period tO 3d,The Propf tor,Partners or.Exeoufivo Officers are indu ."(6ly die&box ir all parbloW6111ims r, d ) 21 all omwed or certain partneialofficors excluded. This certifies that the insurance carrier indicated above in box"3"Insures the business referenced above in box'I a"for workers oornpen ation�under the New York State Workers'Compensation Law.(To ww this form;Now York(NY)most be listed under Ijam on the INFORMATION PAGE of the work*W compensation lrrsurancs p:roslcy� The Insurance CarTleiror its licensed agent wwill'send this Certificate of Insurance to the entity listed above as the tiartificate holder in box'T- The lnsunume carrier must notify the above certificate holder and the Workers"Comoerisatlnn 60ard within 10 days IF a ply Is canceled due to noinpayment of premiums or within 30 days IF there are reasons other than nonpayment of prerniums that cancel the policy or eliminate the insured from the coverage Indicated on this Certificate,(These notices may to sent by regular mall.)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 infonnation only and confers no rights upon the car(ifr ate holder.This corlsf'mcate does not amend, extend or alter the coverage afforded by the policy listed,nor does it confer any right$or respsonsibilities beyond those con,tamed In the re nced policy. -this certtlioate may be used as evidence of a 1Norkene Compensation contract of insurance only`while the underlying policy is in effect. r.Upon cancellation of the;workers"cornponsatidn p6licy-IndloMsd on this faun,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"Cornpensatiion Coverage or other authorized proof that the business Is complying with the mandatory coverage requirements of ft Now Yortr 5 ` Till Compensation Low. Under penalty of perjury,I certify that I am an authorized son or licensed agent of the,Insurance curler referenced above and that the named insured has the coverage as dopildod on this form. .Approvers by: Laurie ulllivsrt Prfnt rMme of atmlt r r rrrsarmrati"of krmnr d s4ont of wituranco rWi Approved by: J a XX (sbcrr i It'lalo Title: Underwriter Supervisor Telephone Number of authorized representative or kcensed agent of insurance carrier 631-363-5200 Pless,a 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.ny.gov,