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HomeMy WebLinkAbout51275-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#: 51275 Date: 10/11/2024 Permission is hereby granted to: Emily Cochran 65 Garden Ct Southold, NY 11971 To: Install roof mount solar to existing single family dwelling as applied for. Disconnects must be located on the exterior, labeled, and readily accessible. Premises Located at: 270 Boisseau Ave, Southold, NY 11971 SCTM#63.-3-6 Pursuant to application dated 08/23/2024 and approved by the Building Inspector. To expire on 10/11/2026. Contractors: Harvest Power LLC Work: (631)647-3402 Islip Terrace, NY 11752 Required Inspections: Fees• SOLAR PANELS $100.00 ELECTRIC -Residential $125.00 CO-RESIDENTIAL $100.00 Total $325.00 ��Building Inspector TOWN OF SOUTHOLD—BUILDING DEPARTMENT F Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 Telephone (631) 765-1802 Fax (631) 765-9502 http s://www,southol_t wn y go APPLICATION FOR BUILDING PERMIT For Office Use Only PERMIT NO. Building Inspector: Applications and forms must be filled out in their entirety.Incomplete applications will not be accepted. Where the Applicant is not the owner,an Owners Authorization form(Page 2)shall be completed. Date: OWNER(S)OF PROPERTY: Name: Emily Cochran SCTM#1000- 63.-3-6 Project Address: 270 Boisseau Ave, Southold Phone#: (631) 291-5859 Email: emilykc86@gmail.com Mailing Address: 270 Boisseau Ave, Southold, NY 11971 CONTACT PERSON: Name: Katelyn Tornetta Mailing Address: 2941 Sunrise Hwy, Islip Terrace, NY 11752 Phone#: (631) 647-3402 =Mail.' ppermitting@harvestpower.net DESIGN PROFESSIONAL INFORMATION: Name: Michael Dunn, R.A. Mailing Address: 256 Orinoco Dr, Br-i4itwaters, NY 11718 Phone#: ( 631) 665-9619 Email: Bayblueprint@aol .com CONTRACTOR INFORMATION: Name: Harvest Power LLC Mailing Address: 2941 Sunrise Hwy, Islip Terrace, NY 11752 Phone#: ( 631) 647-3402 Email: hppermitting@harvestpower.net DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ®Alteration ❑Repair ❑Demolition Estimated Cost of Project: ❑Other $ 35,034.06 Will the lot be re-graded? ❑Yes ONO Will excess fill be removed from premises? ❑Yes ®No 1 PROPERTY INFORMATION Existing use of property: Residence Intended use of property: (no change) Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? ❑Yes ®No IF YES, PROVIDE A COPY. ® Check Box AfterReading: 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 Class A misdemeanor pursuant to Section 210.45 of the New York State Penal Law. Application Submitted By(print name): Ko,L -3<\ —C bC't�� �' [3Aut,hor Zed Agent ❑Owner Signature of Applic Date: STATE OF NEW YORK) SS: COUNTY OF Suffolk Katelyn Tornetta being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)he is the Agent (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 ZIP 1417TARY PUBLIC,STATE OF NEW Y0FK FIS91stration No.OI IA6034714 � wts�xn Stdfolk County PROPERTYOWNERAUTHOR) T OO Eit 3O,20 ._....... �f l ivr_ ej .. , -.— -- .; .......— ._ — I, Emily Cochran residing at 11, Boisseau Ave Southold, NY 11971 do hereby authorize_ Harvest Power, LLC to apply on my behal to the Town of Southol wilding Department for approval as described herein. Owner's S" nat e ID4te Emily Cochran Print Owner's Name 2 Building Department Application AUTHORIZATION (More the Applicant is not the Owner) 1, _Emi I y cochran residing at 280 Ficisseau Ave (print property owner's name) (Mailing Address) Scw rho ld, NY 11971 do hereby authorize. 6Ga f-,e I yn Tornet t a (Agent) Harvest Power LLC to apply on my behalf to the Southold,Building Department. (6wrter' t na re), E,'vwily Cochran (Print Owner's Name) CONSENT TO INSPECTION Emily Cochran ,the undersigned, do(es)hereby state: Owner(s)Name(s) That the undersigned(is) (are)the owner(s)of the premises in the Town of Southold, located at 270 Boisseau Ave, Southold, NY 11971 which is shown and designated on the Suffolk County Tax Map as District 1000, Section 63 , Block 3 ,Lot 6 That the undersigned(has)(have)filed, or cause to be filed,an application in the Southold Town Building Inspector's Office for the following: Installation of a 11.76kw solar system with (28) REC420AA Roof mounted panels 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: .. _ -7 LA .. ._. _....... ( ignatur ) Emily Cochran (Print Name) (Signature) (Print Name) 4, BUILDING DEPARTMENT-Electrical Inspector TOWN OF SOUTHOLD " Town Hall Annex - 54375 Main Road - PO Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1802 - FAX (631) 765-9502 jamesh@southoldtownny.gov— seand southoldtownn . ov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: 8/21/2024 Company Name: Harvest Power LLC Electrician's Name: Carlo Lanza License No.: ME-68518 Elec. email: hppermitting@harvestpower.net Elec. Phone No: (631) 647-3462 Cl I request an email copy of Certificate of Compliance Elec. Address.: 2941 Sunrise Highway, Islip Terrace, NY 11752 JOB SITE INFORMATION (All Information Required) Name: Emily Cochran Address: 270 Boisseau Ave Cross Street: Main Road Phone No.: (631) 291-5859 Bldg.Permit#: email:emilykc86@gmail.com Tax Map District: 1000 Section:63 Block: 3 Lot:6 BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): Installation of a 11.76 kW solar PV system with (28) REC420AA roof-mounted panels. Square Footage: Circle All That Apply: Is job ready for inspection?: YES �✓ NO Rough In �✓ Final Do you need a Temp Certificate?: Z YES F—] NO Issued On Temp Information: (All information required) Service Size''1 Ph❑3 Ph Size: 150 A # Meters 1 Old Meter# 098343614 ❑New Service❑Fire Reconnect[:]Flood Reconnect❑Service Reconnect[:]Underground ✓❑Overhead #Underground Laterals Z 1 2 H Frame D Pole Work done on Service? Y ✓N Additional Information: PAYMENT DUE WITH APPLICATION Suffolk County Dept.of Labor,Licensing&Consumer Affairs MASTER ELECTRICAL LICENSE Name CARLO P LANZA Business Name "I his cortfies that the Harvest Power LLC beater 9s dUJY 4censed License Number ME-68518 by the County of suffNit Issued: 11/30/2023 Je*v*vqer C^ g;�a,,, Expires: 11/01/2025 Commissioner R NEW K 'workers' CERTIFICATE OF INSURANCE COVERAGE YO STATE Compensation Board under the NYS 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 1ame&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured ............. a.Legal N � HARVEST POWER LLC 2941 SUNRISE HWY ISLIP TERRACE, NY 11752-2822 1c.Federal Employer Identification Number of Insured or Social Security Number 204214746 Work Location of Insured(Only required if coverage is specifically limited to certain locations in New York State,i.e., Wrap-Up Policy) 2.Name and Address of Entity Requesting Proof of Coverage(Entity 3a Name of Insurance Carrier Being Listed as the Certificate Holder) HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY Town of Southold b Policy Number of Entity Listed in Box"la" P.O. Box 970 South Hold, NY 11964-0000 LNY713777882 c Policy effective period 10/01/2023 TO 09/30/2024 4.Policy provides the following benefits: ® 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 Si ned 10-012023- E_ 7 .._... ---_ww_...www............. --__._ww__........... (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number (212)553-8074 Name and Title:Elizabeth Tello—Assistant Director,Statutory Services IMPORTANT: If Boxes 4A and SA 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. _... ......wwwww_._._.. �w ............W........ 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 Signed By.gq........... (Signature of Authorized NYS Workers'Compensation Board Employee) [Teltph ne Number Name and Title Please Note: Only insurance carriers licensed to write NYS disability and paid family leave benefits insurance policies and NYS licensed insurance agents of those insurance carriers are authorized to issue Form DB-120.1. Insurance brokers are NOT authorized to issue this form. DB-120.1 (9-17) 111111 I'11111111111°1��'0�9!17IIIIII I H Additional Instructions for Form 1313-120.1 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 York 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 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 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. D113-120.1(9-17)Reverse DocuSign Envelope ID:23FFBA00-E993-4182-B944-CC46A4AB8E3B LJ NEW Workers' CERTIFICATE OF SORK TATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board ---- _._----- _www_..wwww........._................._........ 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured HARVEST POWER LLC 2941 SUNRISE HWY 1c.NYS Unemployment Insurance Employer Registration Number of ISLIP TERRACE,NY 11752-2822 Insured Work Location of Insured(Only required if coverage is specifically limited to 1d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e., a Wrap-Up Policy) Number 20-4214746 2.Name and WAddress of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Indemnity Insurance Co.of North America Town of Southold 3b.Policy Number of Entity Listed in Box 1.1 a" P.O.Box 970 Southold,NY 11964 C55973957 3c.Policy effective period 1 0/0 112 0 2 3 to 10/01/2024 3d.The Proprietor,Partners or Executive Officers are ❑X included.(Only check box if all partners/officers included) ❑ all excluded or certain partners/officers excluded. .......................... as _A ...... 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"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 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: Lex Smith D-1J '1#hWme of authorized representative or licensed agent of insurance carrier) 9/8/2023 Approved by (Signature) (Date) Title: Assistant Pr ram Manager Telephone Number of authorized representative or licensed agent of insurance carrier: 214-721-6248 Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-106.2.Insurance brokers are NOT authorized to issue it. C-105.2 (9-17) www,wcb.ny.gov Acct#:2830004 a § @ o � 3 U ® S � . ) § G § § § W C } § § § ) / ' m j : � 2 @ ��y:,. ■�r g { . �7o � a � � \A2� YORK Workers' CERTIFICATE OF INSURANCE COVERAGE snarl= Compensation Board under the NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by Disability and Paid Family Leave YBenefits Carrier or Licensed Insurance Agent of that Carrier ............ _ ..-................................ 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured HARVEST POWER LLC 2941 SUNRISE HWY ISLIP TERRACE,NY 11752-2822 1c.Federal Employer Identification Number of Insured or Social Security Number 204214746 Work Location of Insured(Only required if coverage is specifically limited to certain locations in New York State,i.e., Wrap-Up Policy) 2.Name aniiAddress of Entity Requesting Proof of Coverage(Entity 3a Name of Insurance Carrier Being Listed as the Certificate Holder) HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY Town of Southold b Policy Number of Entity Listed in Box"la" P.O. Box 970 South Hold, NY 11964-0000 LNY713777882 c Policy effective period 10101/2023 TO 09/30/2024 4.Policy provides the following benefits: ® 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 10-01-2023 7� (Signature of insurance carrier's authorized representative or NYS Licensed Insurance 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 46,4C 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 h..w-.-.--w_.h .......- as 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.... ............... By -. ............. ............ (Signature of Authorized NYS Workers'Compensation Board Employee) Tele hone Number Name and Title Please Note: Only insurance carriers licensed to write NYS disability:and paid family leave benefits insurance policies and NYS licensed insurance agents of those insurance carriers are authorized to issue Form DB-120.1. Insurance brokers are NOT authorized to issue this form. DB-120.1 (9-17) 111111 DB-120.1 09-17IIIIII IH Additional Instructions for Form DBA 20.1 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 York 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 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 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-1 20.1(9-17)Reverse DocuSign Envelope ID:23FFBA00-E993-4182-B944-CC46A4AB8E3B NEW Workers' CERTIFICATE OF YORK STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured HARVEST POWER LLC 2941 SUNRISE HWY 1c.NYS Unemployment Insurance Employer Registration Number of ISLIP TERRACE,NY 11752-2822 Insured Work Location of Insured(Only required if coverage is specifically limited to 1d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State, i.e.,a Wrap-Up Policy) Number 20-4214746 ............. _w..__...._._� ..............__._..............._ww. _w_w_...__._....... 2. Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Indemnity Insurance Co.of North America Town of Southold 3b.Policy Number of Entity Listed in Box"1 a" P.O.Box 970 C55973957 Southold,NY 11964 3c.Policy effective period 10/01/2023 to 10/01/2024 3d.The Proprietor,Partners or Executive Officers are ❑X included.(Only check box if all partners/officers included) ❑ an 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 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"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 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: mi 0-10MM hWme of authorized representative or licensed agent of insurance carrier) 9/8/2023 Approved by: (Signature) (Date) Title: As�sis&�nt P gggLm ManAgerv� Telephone Number of authorized representative or licensed agent of insurance carrier: 214-721-6248 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.ny.gov Acct#:2830004 Client#: 110076 HARVPOW -DATE(MM/DDIYYYY) ACORDTM CERTIFICATE OF LIABILITY INSURANCE 4/16/2024 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 INSURE.. i ... ........... ..... ...se ....... .. ............... _... D 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 any rights to the certificate holder in lieu of such endorsement(s). PRODUCER N o �. Commercial Support Ed ewood Partners Ins.Center PH NIf i NIR 631-390-9700 fA� 40 Marcus Drive 3rd Floor E � tit/. trI .. ... . A R s: NEcertlflcates@eplcbrokers.com Melville, NY 11747 INSURER(S)AFFORDINGCOVERAGE NAIC q .James River ns......_..,..._._..,_, ........................................ ..,....., INSURER A: Ri Insurance Company 12203 INSURED ....--.....................-........_._. ...., ... ,.., .INSURER B:Lloyd's of London ....,_,_,_,..._._..................,.,.....,... ............ .. ......... . ._. .... Harvest Power LLC,Friendly ............. Construction Company Inc,EZ Flashing LLC INsuRERR C D: 2941 Sunrise Hwy ..... ......... ...____. .. ............... . ............_ � ,. R Islip Terrace,NY 11752 _INSURER......E: .... ... ._._._... ......._.... .......... ... ... ......... ....... ...... INSURER F 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 CONTRACTOR 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 PAIDCLAIMS. �p X�IdYYYY ..................... AR .. I SUER NI 0007.....,,. POLICY'`EFF �`P I Y XP ..m. E LIMITS L TYPE OF INSURANCE POLICY NUMBER IMMIDD/YYYYII° I ) mN WW nn COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,,11808 4/15/2024 04115/202 _ . .. 0000 00 CLAIMS-MADE X OCCUR REA.ISES �aoGEDnre $50, , X Contractual Llab. �MED EXP(Any one person) $Excluded .. .... Xp $5,Q0QDed . PERSONAL ... $ " _ _ .. ..... ... 1r000TOOO EN POLGICYEGX w.. AGGREGATE $ �_0r000..... ..PRODUCTS- $2 I�LIMITA APPLIES 21000z000 PRO- JECT 'LOC .. PER: GENERALA COMP/OP„ _... W OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMITT ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY HIRED NON-OWNED (Par $ (, 'AUTOS ONLY AUTOS ONLY .(,......,..... ROPtRTY DAMAG......... ..., _.,....... .. .. ..,'. ........ ..,,,,... .._. .., ....... A ..._X AB 000711797 4/15/20 X.. occuR . UMBRELA LI..... . ......._... ......... ...........,.._.. w...... .... 24 04/15/202 EACH OCCURRENCE $4,QQQ,000 L EXCESS LIAB CLAIMS MADE ,AGGREGATE I$4 000 000 AN.�EO WO RKERS COMPENSATION PER OTH O EMPLOYERS*LIABILITY YIN �Ti ICE w...... FR_..__... -w F V CEa W ER EXCL UDEDI E L EACH ACCIDENT $ANY PR,OPRIE'TORI'PARI'NERlEXECUTIVE❑ N/A E tory ki L DISEASE EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E L DISEASE POLICY LIMIT $ A ..PollutionLlab. 0007.... ........ _._........ .. ..... ............. .�_..........__��_�_ .. 11808 4/15/2024 04/15/202 $1MM Ea Claim/$1MM Agg B Professional Liab HPL230064 04/1512024 04/16/202 $2MM Ea Claim/$2MM Agg $10K Ded Ea Claim DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Evidence of Insurance CERTIFICATE HOLDER CANCELLATION Town of Southold SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN P.O. Box 970 ACCORDANCE WITH THE POLICY PROVISIONS. South Hold, NY 11964-0000 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) 1 of 1 The ACORD name and logo are registered marks of ACORD #S6497815/M6497588 RH002 Client#: 110076 HARVPOW _ DATE(MM/DD/YYYY) ACORDTM CERTIFICATE OF LIABILITY INSURANCE 4/16/2024 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 any rights to the certificate holder in lieu of such endorsement(s). PRODUCER j Commercial Support Edgewood Partners Ins.Center PHcrNE ' 631-390 9700 " 40 Marcus Drive 3rd Floor E-MAILNg'As iA/c,Nei ADDres, p o rokers com NEcertjfiwsuRs a is Melville, NY 11747 _"" NAIL# INSURER B. y COVERAGE W ) _...,w_....__.... 12203 ...,___ ..... ..._....�, ......._,,,,,,..._. .._. INSURER A:James WRiver Insurance Company, .... ...._.� ............. ..,.......... INSURED Lloyd's of London Harvest Power LLC, Friendly ......1.1 ... _._ .—.,,. m.m ._. ....................._. :INSURER C Construction Company Inc,EZ Flashing LLC INSURERo¢._..... -............... 2941 Sunrise Hwy P _ _.. INSURER-„ Islip Terrace,NY 11752 INSURER F 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 CONTRACTOR 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. . ... POLICY NUMBER M10 Y°yY r�OLICY EXP LIMITS AR COMMERCIAL OGENERAL LABI ADD, 14 ,.1.1-. .... .._---_... iP LICPEw ).��DD/YYVY�-................... Ilffk .. LIABILITY 000711808 4/15/2024 04/15/202 EACHOCCURRENCE $1 OOO O00 r, CLAIMS-MADE [XI''..OCCUR pR RENTED r OLOOO X $5,000 Dedl Liab. P ED ExP(Any one person) $Excluded PERSONAL&ADV INJURY $1000rOOO PENERALAGGREGATE $2,000AOOO N'LAGGREGATELIMITAPPLIESPER: G GE . ',. POLICY .. ....... .'_ .mow..._ .. .............._... .... ............... .... ....... CEr.4k')'ikJiw'G5tlP9GLLAtiT.. .$. .#.. OTHER 0 X JECI` LOC RODU CTS COMPIOPAGG $2 000,OO AUTOMOBILE LIABILITY I»a cIa9E?4)............................. . ... ........ ANY AUTO ,BODILY INJURY(Per person) $,,,,, ......... OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS ._. ..........-,m..,v ..,. ..„_...HIRED NON-OWNED F^ICDP'ER7"Y DAMAC+'L $ AUTOS ONLY AUTOS ONLY ...)'er af!a)t).... .... .... ...... ......., .................,,.,........_.. $ ._ . EXCESS LABCLAIMS-MADE ...... ... .... ..... ....... .. ......... ........ ......... '... ., ..... ACH OCCURRENCE $4000,000 X occuR 000711797 4I1S/2024 O4MS/2O2 EGGREGATE $4,000 OOO .. X UMBRELLA A CLAIMS MADE A AN...WORKERS RETENTION$ . ... .. . ..,� ......................... ....._... .. ....... ...... .....,.,..... ......... ..,.... .. ..... ... DED $ COMPENSATT ION PER OTH D EMPLOYERS'LIABILITY -- .S.AI4J.L YIN Y PROPMETOR/PARTNER4,XECUTIVE E L EACH ACCIDENT I$ FACE RWEMBER EXCLRfDED? N/A (Mandatory In NH) E.L DISEASE EA EMPLOYEE $ If yes,describe under j DESCRIPTION OF OPERATIONS below ...w..,,.,�.. ........... _. ............. ............. �_�.w...,.... .. ..w...„,,,,. .. . .... ...._.......,...-w-_....,. ..... .........,.... ......... ----..----. ..._.....E L DISEASE POLICY..LIMIT `_$.-..--...... ... A 'Pollution Liab. 000711808 4/15/2024 04/15/202 $1MM Ea Claim/$1MM Agg B Professional Liab HPL230064 4/16/2024 04/15/202 $2MM Ea Claim/$2MM Agg $10K Ded Ea Claim DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Evidence of Insurance CERTIFICATE HOLDER CANCELLATION Town of Southold SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 53095 Route 25 ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 1179 Southold, NY 1 1 971-0000 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) 1 of 1 The ACORD name and logo are registered marks of ACORD #S6497816/M6497588 RH002 Client#: 110076 HARVPOW =24 ACORDTM CERTIFICATE OF LIABILITY INSURANCE D/YYYY) 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. PORTANT:If the certificate holder is an ADDITIONAL INSURED,the olic 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 any rights to the certificate holder in lieu of such endorsement(s). g Support PRODUCER PMT Commercial A/c N 631 390 97µ rw 40 Marcus Drive 3rd Floor F EtNEcertificate 0 icCNi Ed ewood Partners Ins.Center PHONE 9 .......... ...w.w. , s picwbrokers com..,..._.,___.. Melville,NY 11747 INSURER(S)AFFORDING COVERAGE NAIC# ......._..._... James River insuranc..... ................ INSURER---A. e Company 12203 INSURED INSURER B:Lloyd's of London Harvest Power LLC,Friendly .....- .-. _......... ER C Construction Company Inc,EZ Flashing LLC ...._._._ . _ ._..... INSURER D:. 2941 Sunrise Hwy _ ............ ...... ... INSURER E; Islip Terrace, NY 11752 ...... ............... INSURER F 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 CONTRACTOR 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. SUB ' POLICY EFF POLICY EXP _........ ...... AR ..X I— I .,. ADOL��..._._.. .. LIMITS COMMERCIAL GENERAL LIABILITY ....�.�� .... _..,__.��...,._ ......�..... ..I .....,. ...._.�.I .� E .... .. ..... .......,.. TYPE OF INSURANCE POLICY NUMBER FOLIC YYYY POLICY/YY EACH OCCURRENCE $1 OOO OOO 000711808 4/15/2024 04/15/2025 ®..µ.................�.......� ..... CLAIMS-MADE X OCCUR f E�..ap�,rr,Pn„cP,) _ $BO,OOO X Contractual Liab. MED EXP(Any one person) s EXCluded __.... . _._ _.....__DV IN.....RY.... X $5,000 Ded. PERSONAL&ADVINJURY $1 OOOr000 ..LOPOTILIE.- NCYE�PROT AP� ���.................... .�.. EJIS PER: GENERAL AGGREGATE s2,000,000 GER: X JECT LOC cMBdNEtaSfhJCaLE IMIf 2._.,..._...... .....�.�.w.....,.. ............. ..._.. .... ..... ..,.�...�... _....R: AUTOMOBILE LIABILITY ~~� Ep poepi ANY AUTO BODILY INJURY(Per person) I$ INJURY(Per accident) $ A AUTOS.......,.. AHIRED UTOS ONLY NON-OWNED ONLY Rt PLR'r`f C)Af>vSR`a� $ OWNEDONLI SCHEDULED AUTOS BODILY ^"'-__...�-'_" _... .... ...... .....�.�......,..._ ................... .. ... ......... ..,,,... ...... .-.._...........----- ....._ ...... .$ A X EXCESS LIAB X CLAIMS MADE 000711797 4/15/2024 04/15/202 AACH OCCURRENCE $4,,000,000 UMBRELLA LIAB ...... .. GGREGATE WORKERS C RETENTION$ ,,,,, ,. .... . ..f OMPENSATION......... ... ._.... ....... ....,,,,, _. .,.._..„. .,..,_...........w... .,.._. . ............,...._ .. ._.. .....�T. T.U.T.E.. ..,,,, H.i',$ Y/N . .. .... ANY OFFICER/MEMBER PROPRIETOR/PARTNER/EXECUTIVE N/A E L EACH ACCIDENT $ AND EMPLOYERS'LIABILITY (Mandatory in NH) ❑ E L DISEASE EA EMPLOYEE$ If yes,describe under DESCRIPTION OF OPERATIONS below E L DISEASE POLICY LIMIT $ ......... ......... . ......._... .. ......,,,,, ... ... -............ -, ............ .m ................, .... .... _. ............. ..,,,,.......... ..:.......... ...... A Pollution Liab. 000711808 04/15/2024 04/151202 $1MM Ea Claim/$1MM Agg B Professional Liab HPL230064 04/15/2024'04/16/202 $2MM Ea Claim/$2MM Agg $10K Ded Ea Claim DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Evidence of Insurance CERTIFICATE HOLDER CANCELLATION Town of Southold SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN P.O. BOX 970 ACCORDANCE WITH THE POLICY PROVISIONS. South Hold, NY 11964-0000 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) 1 of 1 The ACORD name and logo are registered marks of ACORD #S6497815/M6497588 RH002 Client#: 110076 HARVPOW =4,,6,m2'024 /YYYY)ACORDTM CERTIFICATE OF LIABILITY INSURANCE 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 polic ies must have ADDITIONAL INSURED provisions or be ........ y(' ) p 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 any rights to the certificate holder in lieu of such endorsement(s). PRODUCER N 07' Commercial PP , u o Edgewood Partners Ins.Center 631 .. 9700 N�rl 40 Marcus Drive 3rd Floor E MAID NEcertificaltes a icbrokers com I Melville,NY 11747 P AFFORDING COVERAGE �NAIC# INSURER................�...._.._ ... _. ....... ......... _�....,,,,,, ...,.,,... � suRER n Jame . -. RiverRer Insurance Company .... ._... �12203 Harvest Power LLC,Friendlyg ?!,,, INSURED INSURE B Lloyd's Of London Construction Company Inc,EZ Flashing LLC INSURER D 2941 Sunrise Hwy --. Islip Terrace, NY 11752 INSURERE _........... ......... ..........._ INSURER F: 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 CONTRACTOR 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 ... ...._µSU A ..� �ADDL7S1dBR ....... .. ._POLICY EFF POLICY EXP � LIMITS LTR INF3 IML.4. ........... .... ... i._.....-. ) 6...... l...,, A MMIDDIYYYY MMIlapmrvY T �(�ANTED $1000z000 ..�����.. ........ .. .. ACH OCCURRENCE COMMERCIAL GENERAL w TYPE P LI CLAIMS-MADE XIoccuR 000711808 4115/2024 04/15I2025 E,N�ME axance) $50�000 """"""""""" .. _ .. X $5,000 Contractual Llab MED EXP(Any one person) �$Excluded ......... .. (" X Ded PERSONAL&ADV INJURY $1,000,000 E s200� # .GEN'L AGGREGATE LIMIT APPLIES PER: 'GENERALAGGREGATmmµ " .., PRO LOC $.. POLICY XM JECT C PRODUCTS COMP/OPAGG $2000,000 ...,_.., ANY AUTO II U $ C MBNNED S4NC LL L Mtl pers on) $ AUTOMOBILE LIABILITY BODILY INJURY(Per�....._... _.„ ....... _. OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLYAUTOS AUTOS ONLY .......... NON-OWNED ONLY LROF"L.RA"r t"DAMA,O. $ bye¢btGrtcSe' .,.. .., .,.... ..LA LIAR 00711797 04/16/2024 04/15/202 ,E W CC _.._f_$_,. .. ......EXCESS LIAB X OCCUR MADE ......, 0..,„_._.,_ ....... ............�...._........ ...... _....... AGGREGATE ....w.. ... ....5�QOO QUA UMBREL ACH OCCURRENCE $4 000000 .... A X A,,, _DED RFTE TIONS,, $ WORKERSCOMPENSATL.. ...,_....Y./.N .. ... ....... ....w .. ._.,... ......... .._..........� ......_,... .... ..,,,,........w.„. . ..._ _ .. C ON I PTfMTIMIT I OTH AND EMPLOYERS'LIABILITY " F "ER """" y ACCIDENT $ (Mandatory in NH) _,.. E EA EMPLOYEE1$ If es,describe under li ANY PROPRIETOR/EXCLUDED? OFFICER/MEMBER EXCLUDED? NIA ' DESCRIPTION OF OPERATIONS below E L DISEASE POLICY LIMIT $ A ...Pollution Liab. ._.._ .. w....., __...... 0007......_... ... ...rrrr_ ...... . .......... ... ....... E L DISEA._ .... _..... _. .w... _...... .. ......... 11808 4/15/2024 04/15/202 $1MM Ea Claim/$1MM Agg B Professional Liab HPL230064 4/15/2024 04/15/202 $2MM Ea Claim/$2MM Agg $10K Ded Ea Claim DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Evidence of Insurance CERTIFICATE HOLDER CANCELLATION Tow of Southold SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 53095 Route 25 ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 1179 Southold,NY 11971-0000 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) 1 Of 1 The ACORD name and logo are registered marks of ACORD #S6497816/M6497588 RH002