HomeMy WebLinkAbout51618-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#: 51618 Date: 02/07/2025
Permission is hereby granted to:
William Leonardi
PO BOX 355
Laurel, NY 11948
To:
Install replacement windows in-kind to a single-family dwelling as applied for.
Premises Located at:
255 Woodside Ln, Laurel, NY 11948
SCTM# 127.-9-30
Pursuant to application dated 12/11/2024 and approved by the Building Inspector.
To expire on 02/07/2027.
Contractors:
Required Inspections:
Fees:
Single Family Dwelling- Alteration $250.00
CO-RESIDENTIAL $100.00
Total $350.00
��� Building Inspector �� �
Docusign Dwelope ID,53A644A4-1432-40FA-BBD4-D9A7F584EACB
TOWN OF SOUTHOLD—BUILDING DEPARTMENT
Town 1Hall Annex 54375 Main Road P. O. Box 1 179 Southold,NY 1 1971-0959
Telephone(631) 765-1802 Fax (631) 765-9502 htws:/(AVW AQL1 1101j or Itta
Date Received
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
Owner's Authorization form(Page 2)shall be completed.
Date: 12/2/24 _
OWNFRjS)Of PROPERTY:
�, �,,...m.,_.....�...___. _......,. ...� �._
Name: William Leonardi SCTM# 1000
Project Address: 255 Woodside Ln.
Phone#: 631-484-1031 Email: beerbill@aol.com
Mailing Address: 255 Woodside Ln. Laurel NY 11948
CONTACT PERSON:
Name: Scott Doughman - Go Permits
Mailing Address: 105 Buttonball Ln. Glastonbury, CT 06033
Phone#: 303-946-8685 Email: permits@gopermits.org
DESIGN PROFESSIONAL INFORMATION:
Name:-n/a
Mailing Address
Phone#: Email;
CONTRACTOR INFORMATION:
Name: Home Depot USA
Mailing Address: 2455 Paces Ferry Rd. Atlanta, GA 30339
Phone#: 303-946-8685 Email: permits@gopermits.org
DESCRIPTION OF PROPOSED CONSTRUCTION
C New Structure ❑Addition ❑Alteration R Repair ❑Demolition Estimated Cost of Project:
E Other Remove and replace 2 windows,same size,no structural change. $ 3106
Will the lot be re-graded? ❑Yes BNo Will excess fill be removed from premises? ❑Yes BNo
1
Docusign Envelope ID:53A644A4-1432-40FA-BBD4-D9A7F584EACB
PROPERTY RTY INFORMATION
Existing use of property: Single family intended use of property: Single family
Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to
this property? DYes ❑No IF YES,PROVIDE A COPY.
IN Check,Box;After Reading. ow o wnat/contr /design intri ticanal Is mpoasltde for all drama a and storm water lww5 as provided by
chapter 236 of the Tom Lode tl t"ilON IS HERI rr MADE to the Building Dquttorent for the issuartm of a building Permit pursuantto the s uiltitarp Zone
Ordina to of tt6wrr"rown of Southold,Suffolk,Couro,Now York end r aprpltcabla Cam,Ordinanm of li cations"tot the construction of bult'
additl sr alllrwrai ana orfor ma towal Asir deasolftion as'herein described,The applicant a rM, to comply v4tb:all a pirticable laws ordfnanr.aa,building code,
houft cWt and repbOmts and toalldmit auttadriteet Irmpettors on premMs,and un b4din lsl for rw t+essartr Inwettions.False statanaaarctts made herein are
punldrblo riclaw anal Naxnaanidr rararratrtto actionttrr o fiatduorortrstatd Penal Law.
Application Submitted By(print name): Jennifer Winke-Go Permits BAuthorized A ent ❑Owner
Signature of Applicant: --, Date: S�a`�
STATE OF NEW YORK)
SS:
COUNTY OF._wwwwwwww._._._........... )
Jennifer Winke 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 meth I s
ay
of
uZRn Not ry ubk
NOTARY PUBLIC
Guilford County,NC
L
ommission �� UTHORIZ T
ere t e applicant is not the owner)
William Leonardi 255 Woodside Ln.
,, William .. _ w residing at__ www �..._..............._._........
�.._.
do hereby authorize Jennifer Winke-Go Permits to apply on
mabAlfto the Town of Southold Building Department for approval as described herein.
WI�AiM �l bVt AYd l 12/4/2024
; arM�" rcr ."r* Signature__. .. �._�..�,..._....�......... Date
William Leonardi
w Print Owner's Name
. .._._._........
2
-kogd
APPROVED AS NOTED
B.P 1le ! + COMPLY WITH ALL CODES OF
F��6 BY: YORK STATE&TO CODES
NOTIFY BUILDING DEPARTMENT AT CONDITIONSAS REQ IRED AND
631-765-1802 8AM TO 4PM FOR THE RUMTOWNZM
FOLLOWING INSPECTIONS: MULDTOWNPONINGBOR
FOUNDATION-TWO REQUIRED Sommm'
FOR POURED CONCRETE Itys.mc
ROUGH-FRAMING&PLUMBING EMIR
INSULATION
FINAL-CONSTRUCTION MUST
BE COMPLETE FOR C.O.
ALL CONSTRUCTION SHALL MEET THE
REQUIREMENTS OF THE CODES OF NEW
YORK STATE. NOT RESPONSIBLE FOR
DESIGN OR CONSTRUCTION ERRORS
"P CUSTOMER TOTALS COPY I1/2512024
�„
t ,w,� � 11/26/2024
QUOTATION #3060579 Denise Harris
S I MONTO SOLD TO: SHIP TO:
I N 1? W N The Home Depot THDiLONG[SLAND-Bauppauge EAST
Accounts Payable B-12 Hauppauge Branch
2455 Paces Ferry Road NW 40 Oser Avenue
Atlanta,GA 3039-4024 Hauppauge,NY 11779
Phone:631-478-6101 Phone:631-478-6101
Far: Fax:
ILI
53984249 Leonardi Unassigned
1
1 6500 Double.Hung 31.75" X 53" Operation
RO: Operating, Frame=Replacement,Ext. Color=
White,Int. Color=White,Glass Package=
32 x 5a.5 ENERGY STAR North Central V7.ProSolar Low E
Room ID: PLUS.Argon,Supercept,7I8"IGU, Glass Thickness
Custom = 1/8 in- 1/8 out DS,Upper=Annealed,Lower= `"
Bedroom 2 Annealed,Locks=2,White;Cam,Air Latches=2,
Sill Extender,Head Expander. Screen Coverage= o`
Full,Fiberglass,Extruded,U-Factor—0.25, SHGC—
0.25,VT=0.48,STC=28,CPD Number=SBP-A-
44-74448-00001,Meets Energy Star Zones=North
Central,DP=50,AAMA,
Initials:
I 6500 Double Hung 31.75" X 53" Operation=
RO: Operating, Frame=Replacement,Ext. Color=
32 x 53.5 White, lrit. Color=White,Glass Package=
ENERGY STARNorth Central V7,ProSolar Low E
Room ID: PLUS,Argon,Supercept, 7/8"IGU, Glass Thickness
Custom = 1/8 in- 1/8 out DS,Upper=Annealed, Lower= ' ```
Bedroom 2 Annealed,Locks=2, White;Cam,Air Latches=2, "
u�
Sill Extender,Head Expander. Screen Coverage
Full,Fiberglass,Extruded,U-Factor=0.25, SHGC=
0.25,VT=0.48,STC=28,CPD Number=SBP-A-
44-74448-00001, Meets Energy Star Zones=North
Central,DP=50,AAMA,
•-- RO-32 —.
Initials:
Page 1 Of 2 Quote#: 3060579
T521 Home Improvement Agreement: Page 1
Home Depot License#'s-For the most current
Adam Friedman
Salesperson Name Registration CA,CT,ME,MD,MI,NJ,DC only
Home Depot U.S.A.,Inc. ("Home Depot") or its Authorized Service Provider named below will furnish, install, or
service the equipment listed below at the price,terms,and conditions set forth in this Agreement.
1. Service Provider Contact Information
The Home Depot The Home Depot
Service Provider Contact Name Service Provider Company Name
(631) 478-6101 custon,iercaric,,ellationnortheast@homedepot.com
Phone# Service Provider Email Address
2. Customer Information
[Le o n a—rcri ------ [Wi I—ria—m— Long Island
Customer Last Name Customer First Name Store#/Branch Name Customer Lead/PO#—
L— ---- -- =Lame----�= F�--= E1=94
ETi !,,d id,L,,
Customer Address city State Zip
I)ee(°bili@aol.com
aol.corn
F(631) 484-1031
E==
Home Phone4l Work Phone# Cell Phone# Customer Email Address
3.NOTICE Of RIGHT TO CANCEL
YOU MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR OBLIGATION BY CONTACTING
THE SERVICE PROVIDER OR STORE DIRECTLY; EMAILING SERVICE PROVIDER AT:
OR DELIVEI2iNTG WRITTEN NOTICE TO HOIVTE DEPOT AT:
Address C-ity State Zip
MIDNIGHT ON THE THIRD BUSINESS DAY AFFER SIGNING, J . 1.1,111 THE k",TE
SUPPLEMENT PROVIDES A DIFFERENT CANCELLATION PERIOD. THE STATE SUPPLEMENT
CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN YOUR STATE.
YOUR PAYMENT(S) '�ArILL BE RETURNED WITHIN TEN (10) BUSINESS DAYS AF-11,11 HOME
DEPOT'S RECEIPT OF YOUR NOTICE. ANY MERCHANDISE OR MATERIALS DEI.,lVERED TO
YOU MUST BE MADE AVAILABLE FOR PICKUP BY HOME DEPOT OR SERVICE PROVIDER
AT YOUR ADDRESS LISTED ABOVE AND IN SUBSTANTIALLY 'THE SAME CONDITION AS
WHEN DELIVERED. YOU MAY ALSO CONTACTHOME DEPOT FOR INSTRUCTIONS REGARDING
RETURN SHIPMENT AT HOME DEPOT'S EXPENSE.
THE LAW REQUIRES THAT THE HOME DEPOT GIV YOU A NOTICE EXPLAINING YOUR RIGHT
TO CANCEL. PLEASE SIGNBELOW TOAC ' OW4 DGE THAT YOU HAVE BEEN GIVEN ORAL
AND WRITTEN NOTI Jt RIGHT T ,CA
Acknowledged by: ff/18']2
Cus )nier's Signature Date
460 Standard Form HIA(13 Aug.24)(E) Generated Dare 11118/2024 Lead/P00 F47393298 v 4.0 0
Home Improvement Agreement: Page 2
4. Description of Work to be Performed
A, detailed description of the work to be performed is included in the paragraph or document entitled Scope of
Work, Specification, Customer Summary Sheet, Quote Form, Estimate, Invoice, or Measure which is included in
this Agreement.
5.Anticipated Delivery Date/Installation Schedule
Approximate Start Date: 03/18/202� Approximate Finish Date: H/=17/2=025
All dates are approximate and subject to change due to various circumstances such as weather,manufacturing delays,
obtaining pen-nits or HOA approvals.
6.Electronic Records Authorization
You are entitled to a p�per arid electronic copy of this Agreement it"You, choose. If You consent to an e-mailed
copy, Your consent applies to this Agreement and all subsequent documents and written communications related to
this Agreement. Contact your Service Provider to update Your email address, withdraw Your consent to electronic
records, or obtain a paper copy of the Agreement or related documents at no charge. By providing Your consent
and verifying Your entail address above,"Vou confirm that,You have access to a computer that can receive and open
emails and PDF documents.
7. Contract Price and Payment Schedule
Payment of the Contract Price is due upon signing unless a different payment schedule is required by law,is specified
below, or Is in a payment addendin-n.
Contract Price: $ 13106.88 Includes all applicable taxes.Excludes finance charges.*
Sales Tax: S 0.00 (If applicable, total amount of taxes included in Contract Price)
*41axinrunp deposit OJN7L Y applicable in JID, 41A, ,VIE(33%o),JVJ' F+7(99%)
Deposit% 35.63 Deposit Amount$ Remaining Balance $ [1999_9999
ww
8. .Ftnance Charges
Any interest payments or other finance char Yes will be determined by Your cardholder or loan agreement, to which
Home Depot is NOTa party, and will not akeect the payment due under this Agreement. You are,subject to the terms
and conditions of the cardholder or loan agreement, as applicable. No ffinds should be made payable to Service
Provider, however, Service Provider may collect Your payments made payable to Home Depot,
9. Acceptance and Authorization
By signing below,You authorize Horne Depot to:(a)arrange for Set-vice Provider to perform the Services;or(b)order
and arrange for the delivery of special order merchandise, including any custom made special order merchandise,as
specified in this Agreement. Further,You acknowledge: (i) You have read and understand this Agreement; (ii)'Vou
have accepted this Agreement in its entirety, including the General Conditions and State Supplement (il'any); ii)
You are receiving a complete copy of this Agreement, (iv) all rights and intetests under this Agreement, including
interest in the property Where Services are performed, are solely vested in the person listed as "Customer" above;
and('v)electronic,signatures will be deein originals for all purposes. Do not sign if blank or inconiplete. Service
P vider ,, or pennutirt, it ed to be pro to You in writing at a later date,
rovider's or rmitting inform t'
hima/2624
X ............
. r' Sig at re Date
Custom- *s
X e Depot E/18:1=2024
The Home Depot Digital Signature Date
For questions related to your installation, contact Service Provider at (631) 476-6101
For any other concerns-, contact The Home Depot at 1-800-466-3337
460 Standard Fomi HIA(13 Aug.24)(E) Generated Date 11/18/2024 LeaVPO-.-r' F47393298 v 40 0
.......................
" ]Aompe sCompensationCmpe CERTIFICATE OF INSURANCE COVERAGE
t
" 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
Ia.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured
HOME DEPOT U.S.A.,INC. 678-384-2193
2455 PACES FERRY ROAD NW
ATLANTA,GA 30339 1c.Federal Employer Identification Number of Insured or Social Security
Work Location of Insured(Onlyregtrired if coverage is specifically Number
limited to certain locations in New York State,i.e.,Wrap-Up Policy) 581853319
2.Name and Address of Entity Requesting Proof of Coverage _...._amm........ 3a.Name of Insurance Carrier ...........
.._ ......
(Entity Being Listed as the Certificate Holder) HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY
TOWN OF SOUTHOLD
53095 ROUTE 25
PO BOX 1179 3b.Policy Number of Entity Listed in Box 1 a
SOUTHOLD,NY 11971 LNY713657008
3c.Policy effective period
01-01-2024 to 12-31-2024
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 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 name
insured has NYS Disability and/or Paid Family Leave benefits insurance coverage as described above.
Date Signed 11-20-2023 e "I& reae- __
...... .........n .......,. of insurance carrier's authorized representative or NYS licensed insurance agent of that insurance carrier)...........................
(Signature P 9
10eph,otte,Numher212)553.N074 Namewand Title: ELiZABETH TELL O—ASSISTANT DIRECTOtmSTATUTORY SERVICESww,
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 513 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 139025200.
............ . _.wwwwwwwwwwww............wwww_..........�........�.......mm......_ .�_...w ......._....._.. _.......w......w._... ..__...................
PART 2.To be completed by the NYS Workers' Compensation Board(Only if Box 4B,4C or 58 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 Authorized NYS Workers'Compensation Board Employee) _�M...w..,_..M.....
Telephone Number Name and Title
Please Note:Only insurance cordeds licensed to wfrte NYS disability and Paid Family Leave baertefds®nsrrtarrcca po/tcicr ono hN�3Twr�arpsett rii aarmttce aa�ent ufµ
those insurance carriers are authorized to issue Form DB-120.1.Insurance brokers are NOT authorized to issue this form.
DB-120.1 (12-21) �� II'1111fI1�MII��IIIII�Mal�lll�l
,
Additional Instructions for Form D13-120.1
By signing this form,the insurance carrier identified in Box 3 on this form is certifying that it is insuring the business
referenced in Box la for disability and/or Paid Family Leave benefits under the NYS Disability and Paid Family Leave
Benefits Law.The insurance carrier or its licensed agent will send this Certificate of Insurance Coverage(Certificate)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 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 NYS 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 Insurance Coverage for NYS disability
and/or Paid Family Leave Benefits or other authorized proof that the business is complying with the
mandatory coverage requirements of the NYS Disability and Paid Family Leave Benefits Law.
NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW
§220. Subd. 8
(a) The head of a state or municipal department,board, commission or office authorized or required by law to issue any
permit for or in connection with any work involving the employment of employees in employment as defined in this article,
and not withstanding any general or special statute requiring or authorizing the issue of such permits,shall not issue
such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,that the
payment of disability benefits and after January first,two thousand and twenty-one,the payment of family leave benefits
for all employees has been secured as provided by this article. Nothing herein, however, shall be construed as creating
any liability on the part of such state or municipal department, board, commission or office to pay any disability benefits to
any such employee if so employed.
(b) The head of a state or municipal department,board, commission or office authorized or required by law to enter into
any contract for or in connection with any work involving the employment of employees in employment as defined in this
article and notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into
any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that
the payment of disability benefits and after January first,two thousand eighteen,the payment of family leave benefits for
all employees has been secured as provided by this article.
DB-120.1 (12-21)Reverse
'' � Workers' CERTIFICATE OF
A1ff Compensation NYS WORKERS'COMPENSATION INSURANCE COVERAGE
Board
1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone
__ w...........ww......... ..www-. ...........w
...._..............�__. _..-.-...._.._.. -_... -. ��_a Number of Insured
770-433-8211
Home Depot USA, Inc.
2455 Paces Ferry Rd.,C-20 1c.NYS Unemployment Insurance Employer Registration Numberof
Atlanta, GA 30339 Insured
76011130
Work Location of Insured(Only required if coverage is specifically limited to
certain locations in New York State,i.e.,a Wrap-Up Policy) 1d.Federal Employer Identification Number of Insured or Social Security
Number
58-1853319
2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier --- �
(Entity Being Listed as the Certificate Holder) Indemnity Insurance Company of North America
Town of Southold
53095 Route 25 3b.Policy Number of Entity Listed in Box"la"
Southold,NY 11971 WLR C50670284
3c.Policy effective period
03/01/2024 03.01i2025
to
3d.The Proprietor,Partners or Executive Officers are
❑ included.(only check box if all partnersiofficers included)
FE all excluded or certain partners/officers excluded.
certifies_.._.... ._._.� _._.......................�www_.. _ww.... ........__..__...�...... � www....... ...............�www_._.................. .....wwww......._...............
This ...............www......._
that the insurance carder 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 Item3A
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 orwithin 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: Eric Tonn
.......... ........w ........... _..
(Print name of authorized representative or licensed agent of insurance carrier)
Approved by: -' `% 311124
(Signatue) (Date)
Title: _w __. �.._._._........ Vice President -_................................. �.
Telephone Number of authorized representative or licensed agent of insurance carrier: 67 -7 5-4338
Please Note:Only insurance carriers and their licensed agents are authorized to issue Form C-105.2.Insurance brokers are NOT
Workers' Compensation Law
Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured.
1. 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 a hazardous employment defined
by this chapter, and notwithstanding 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 compensation for all employees has been secured as provided by this chapter. 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 compensation to any such employee if so employed.
2. 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 a hazardous employment defined
by this chapter,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 compensation for all employees has been secured as provided by this chapter.
C-105.2(9-17)REVERSE