HomeMy WebLinkAbout51616-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#: 51616 Date: 02/07/2025
Permission is hereby granted to:
KP Realty of Greenport Corp
1359 Hewlett Ln
Hewlett Harbor, NY 11557
To:
Construct a roofed over structure to include outdoor kitchen,gas fireplace and basement storage
accessory to an existing single-family dwelling as applied for per Trustees and DEC approvals. Must
maintain minimum side and rear setbacks of 15 feet.
Premises Located at:
2006 Gull Pond Ln, Greenport, NY 11944
SCTM# 35.-3-12.11
Pursuant to application dated 12/10/2024 and approved by the Building Inspector.
To expire on 02/07/2027.
Contractors:
Required Inspections:
Fees:
Accessory-New Structure $548.00
CO Accessory Structure $100.00
Total $648.00
Building Inspector
N' srla 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.sot,tlioldt y:own . �o�
Date Received
APPLICATION FOR BUILDING PERMIT
For Office Use Only )d>2� R
PERMIT NO. / w Building Inspector: �
P i.._
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.
OWNER(S)OF PROPERTY:
Name:KP REALITY OF GREENPORT CORP. =CTM
1000-35-3-12.11
Project Address:2006 GULL POND LANE, GREENPORT, NY 11944
Phone#:(917) 797-6253 Email:KARENADLER814@GMAIL.COM
Mailing Address:1359 HEWLETT LANE, HEWLETT, NY 11557
CONTACT PERSON:
Name:KAREN ADLER (PRESIDENT); PASQUALE VARDARO (VICE PRESIDENT)
Mailing Address:1359 HEWLETT LANE, HEWLETT, NY 11557
Phone#:(917) 797-6253 Email:KARENADLER814@GMAIL.COM
DESIGN PROFESSIONAL INFORMATION:
Name:THOMAS PETER DOMANICO ARCHITECT
Mailing Address: 108 MERRICK ROAD, LYNBROOK, NY 11563
Phone#:(516) 887-7147 Email:THOMASDOMANICO@AOL.COM
CONTRACTOR INFORMATION:
Name:PLATINUM SITE DEVELOPMENT, INC
Mailing Address:286 ROUTE 109, FARMINGDALE, NY 11735
Phone#:(516) 681-0090 Email:BRUPNARINE@PLATINUMSDGROUP.COM
DESCRIPTION OF PROPOSED CONSTRUCTION
❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project:
OOther AUXILLARY STRUCTURE W/FIREPLACE AND OUTDOOR KITCHEN
Will the lot be re-graded? *Yes ❑No Will excess fill be removed from premises? ❑Yes ❑No
MINOR REGRADING
PROPERTY INFORMATION
Existing use of property: RESIDENTIAL Intended use of property:RESIDENTIAL
Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to
R-80 I
this property? E]Yes ANo IF YES, PROVIDE A COPY.
@Check Box After Reading: The owner/contractor/design professional Is responsible for all drainage and storm water issues as provided by
Chapter 236 of the Town Code. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the Building Zone
Ordinance of the Town of Southold,Suffolk,County,New York and other applicable Laws,Ordinances or Regulations,for the construction of buildings,
additions,alterations or for removal or demolition as herein described.The applicant agrees to comply with all applicable laws,ordinances,building code,
housing code and regulations and to admit authorized Inspectors on premises and In building(s)for necessary Inspections.False statements made herein are
punishable as a Class A misdemeanor pursuant to Section 210.45 of the New York state Penal Law.
Application Submitted By(print name): k.-t— A Ae-, ❑Authorized Agent E Owner
Signature of A lica� _ Date: (L—1 G^2..'7
g p �. .
STATE OF NEW YORK)
SS:
COUNTY OF
Z4,4eo� being duly sworn, deposes and says that(s)he is the applicant
(Name of individual signing contract)above named,
(S)he is the
(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 there w" Vim., "
Vt)c
tk
Sworn before me this NOT,4F"pU'B iDLIf�IC,State of N o
No. 5087 06
day of , ,»_ _ 20 2 7 died in Nassau Coln
(y commiwmI1 C
PROPERTY NE AUTHORIZATION
(Where the applicant is not the owner)
I, residing at
do hereby a ize to apply on
my behalf to the Town of Southold Building Depa f'It for a val as described herein.
Owner's Signature
Owner's Name
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
n � n%f arnesh southoldtownl ov - seand soutoldtornn . ov
APPLICATION FOR ELECTRICAL INSPECTION
ELECTRICIAN INFORMATION (All Information Required) Date:
Company Name: GJS Electric LLC
Electrician's Name: Gary Salice
License No.: ME-4839 Elec. email:Gary@NFAV.com
Elec. Phone No: 631-298-4545 El request an email copy of Certificate of Compliance
Elec. Address.: 6615 Main Rd, Mattituck NY 11952
JOB SITE INFORMATION (All Information Required)
Name: KP REALITY OF GREENPORT CORP.
Address: 2006 GULL POND LANE, GREENPORT, NY 11944
Cross Street: MAIN ROAD
Phone No.: (917)797-6253
Bldg.Permit#: 5 I(v 1 email: KARENADLER814@GMAIL.COM
Tax Map District: 1000 Section: 35 Block: 3 Lot: 12.11
BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly):
ELECTRICAL WIRING TO POOL EQUIPMENT, GFCI OUTLETS FOR OUTDOOR KITCHEN, OUTDOOR FIREPLACE&
TO THE AUXILIARY STRUCTURE
Square Footage:
Is job ready for inspection?: YES []NO F]Rough In F] Final
Do you need a Temp Certificate?: F] YES EJ NO Issued On
Temp Information: (All information required)
Service Size[11 Ph 03 Ph Size: A # Meters Old Meter#
❑New Service❑Fire Reconnect❑Flood Reconnect❑Service Reconnect❑Underg round❑Overhead
# Underground Laterals 1 M2 H Frame Pole Work done on Service? Y EIN
Additional Information:
PAYMENT DUE WITH APPLICATION
Steven Affelt, AIA
PO Box 762 Architecture
Great River,NY 11739 Intelligent Design
(631) 553-6333 Sustainable Building
January 13,2022
TOWN OF SOUTHOLD
Department of Buildings
54375 NY Route-25
Southold,NY 11971
Regarding: 2006 Gull Pond Ln
Greenpoint,NY 11944
Section 35,Block 3,Lot 12.11
To Whom It May Concern,
This letter is written to certify that the storm water drainage for the proposed swimming pool,spa,and
auxiliary structure installation has been reviewed and designed to retain a storm of up to 2"of rain.
The existing system shall be modified as specified in the site drainage plan and supplemented as depicted.It is
my professional opinion and with a reasonable degree of scientific certainty that the newly supplemented
storm water drainage system will prevent from up to a 2" storm from running into the wetlands on and
adjacent to the subject property.
Respectfully,
� F—D
* «t
73'7S1" (
�F N
Steven Affelt,AIA
Great River,NY 11739 PO Box 762 Tele:(631)553-6333 steve.affelt@ginail,com
Steven Affelt, AIA
PO Box 762 Architecture
Great River,NY 11739 Intelligent Design
(631) 553-6333 Sustainable Building
January 13,2022
TOWN OF SOUTHOLD
Department of Buildings
54375 NY Route-25
Southold,NY 11971
Regarding: 2006 Gull Pond Ln
Greenpoint,NY 11944
Section 35,Block 3,Lot 12.11
To Whom It May Concern,
This letter is written to certify that the storm water drainage for the proposed swimming pool,spa,and
auxiliary structure installation has been reviewed and designed to retain a storm of up to 2"of rain.
The existing system shall be modified as specified in the site drainage plan and supplemented as depicted. It is
my professional opinion and with a reasonable degree of scientific certainty that the newly supplemented
storm water drainage system will prevent from up to a 2" storm from running into the wetlands on and
adjacent to the subject property.
Respectfully,
f�S,P,ED A� '
t
DEC 1 2'0'
7A�
OF NS
r
Steven Affelt,AIA
Great River,NY 11739 PO Box 762 Tele:(631)553-6333 steve.affelt@gmail.com
Town Hall Annex µ ��' �Q� Telephone(631)765-1802
631
54375 Main Road � ^� µ, Fax( )765-9502
P. O. Box 1179 �
Southold, NY 11971-0959 �
d
BUILDING DEPARTMENT
NOTICE OF UTILIZATION OF TRUSS TYPE CONSTRUCTION RE-ENGINEI RED
WOOD CONSTRUCTION AND/OR TIMBER CONSTRICTION
Date:
.........Owner: KAREN ADLERPRESIDENT).. . .(PRESIDENT); PASQUALE VARDARO (VICE MmN
Location of Property: 2006 GULL~POND LANE, GREENPORT, NY 11944 „ - ..
Please take notice that the (check applicable line):
X New commercial or residential structure
Addition to existing commercial or residential structure
Rehabilitation to an existing commercial or residential structure
to be constructed or performed at the subject property reference above will utilize
(check applicable line):
_X Truss type construction (TT)
w......._....µµ_ M Pre-engineered wood construction (PW)
w Timber construction (TC)
in the following location(s) (check applicable line):
Floor framing, including girders and beams (F)
Roof framing (R)
Floor and roof framing (FIR)
Signature: .- ..- w._ . ..._.. __.... ._...... .ww_..._.................._.......����....... ........__.�...._........ ., .�............_......._ .._.__......u.....w. ... _
Name (person submitting this form):
Capacity check applicable line
P Y( PP :)
X Owner
_...... Owner representative
TrussReg15.docx Effective 1/1/2015
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BOARD OF SOUTHOLD TOWN TRUSTEES
SOUTHOLD, NEW YORK
PERMIT NO. 10685 DATE: OCTOIIER 16 2024 `
! ISSUED TO: KP REALTY OF GREENPORT CORP. I.
PROPERTY ADDRESS: 2006 GULL POND LANE GREENPORT
�h
SCTM# 1000-35-3-1.2.1.1
r, y
r AUTHORIZATION
I accordance wait the Resolution of the Itcaar4i of Trustees adopted
Code of the Town of Southold and in
to the provisions of Chapter 275 of the To
at ti�te meetiltg held oil Novembr
lKI and in consideration of application fee in the surtt of' LLVOQ,ltaicl by: L L y"C) tK C NPQRR 1,mm4m BE
and subJect to the 1 enns and Conditions as Mated in the Resolution,the Southold Town Board of Trustees
authorizes and permits the following:
N
4 Wetland Permit for removing 1,108sq.1t. of existing grade-level masonry patio and
° 17sq.ft. area of landscape retaining walls; construct 736 sf of"upper" masonry patio,
18.5' x 46' swimming pool with 50 sf hot tub,410 sf of"lower" grade-level masonry °
pool patio, and associated steps and planters; construct 18' x 23.5' roofed-over open
accessory structure, consisting of unenclosed, covered patio (to remain unenclosed),
stone wall for outdoor fireplace, outdoor kitchen, and 16.33' x 21.84' subfloor/basement
for pool equipment/storage; remove 34 if of existing stone retaining wall and construct
+31.51f of new +2.7-ft high stone retaining wall; and to establish and perpetually
maintain a 50-foot wide non-disturbance/non-fertilization buffer adjacent to wetlands
boundary, replacing approximately 3,850 sf of existing lawn with native plantings and
oar allowing for 4-foot wide cleared access path; all as depicted on the site plan prepared
by Thomas Peter Domanico Architect, received on October 16, 2024, and stamped
approved on October 16, 2024.
/ IN WITNESS WHEREOF,the said Board of Trustees hereby causes its Corporate Seal to be affixed,
and these presents to be subscribed by a majority of the said Board as of the day and year written above.
af FO —...n_ .....
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TERMS AND CONDITIONS
The Permittee KP REALTY O CRE NORTCl 006 Gull P n a t,5rq !1Rp m y
______.....................................................................
York as part of the consideration for the issuance of the Permit does understand and prescribe to
the following:
1. That the said Board of Trustees and the T own of Southold are released 15rom any and all
damages, or claims for damages, of suits arising directly or indirectly as a result of any
operation performed pursuant to this permit, and the said Permittee will, at his or her own
expense, defend any and all such suits initiated by third parties, and the said Permittee
assumes full liability with respect thereto,to the complete exclusion of the Board of Trustees
of the Town of Southold.
2. That this Permit is valid for a period of 36 months,which is considered to be the estimated
time required to complete the work involved, but should circumstances warrant, request for
an extension may be made to the Board at a later date.
3. That this Permit should be retained indefinitely, or as long as the said Permittee wishes to
maintain the structure or project involved,to provide evidence to anyone concerned that
authorization was originally obtained.
4. That the work involved will be subject to the inspection and approval of the Board or its
agents, and non-compliance with the provisions of the originating application may be cause
for revocation of this Permit by resolution of the said Board.
5. That there will be no unreasonable interference with navigation as a result of the work herein
authorized.
6. That there shall be no interference with the right of the public to pass and repass along the
beach between high and low water marks.
T That if future operations of the Town of Southold require the removal and/or alterations in the
location of the work herein authorized, or if, in the opinion of the Board of Trustees, the work
shall cause unreasonable obstruction to free navigation,the said Permittee will be required,
upon due notice, to remove or alter this work project herein stated without expenses to the
Town of Southold.
8. The Permittee is required to provide evidence that a copy of this Trustee permit has been
recorded with the Suffolk County Clerk's Office as a notice covenant and deed restriction to
the deed of the subject parcel Such evidence shall be provided within ninety(90)calendar
days of issuance of this permit.
9. That the said Board will be notified by the Permittee of the completion of the work
authorized.
M That the Permittee will obtain all other permits and consents that may be required
supplemental to this permit, which may be subject to revoke upon failure to obtain same.
I L No right to trespass or interfere with riparian rights. This permit does not convey to the
permittee any right to trespass upon the lands or interfere with the riparian rights of others in
order to perform the permitted work nor does it authorize the impairment of any rights, title,
or interest in real or personal property held or vested in a person not a party to the permit.
NEW,'YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION
Division of Environmental Permits,Region 1
SUNY @ Stony Brook.50 Circle Road.Stony Brook,NY 11790
P:(631)444-03651 F:(631)444-0360
www.dec.ny.gov
July 5t", 2022
Karen Adler
Adler Property
2006 Gull Pond Lane
Greenport, NY 11801
Re: NYSDEC# 1-4738-04088/00004
Adler Property: 2006 Gull Pond Lane, Greenport, NY 11944
Dear Permittee:
In conformance with the requirements of the State Uniform Procedures Act (Article 70,
ECL) and its implementing regulations (6NYCRR, Part 621) we are enclosing your permit.
Please carefully read all permit conditions and special permit conditions contained in the
permit to ensure compliance during the term of the permit. If you are unable to comply with any
conditions, please contact us at the above address.This permit must always be kept available on
the premises of the facility.
Also enclosed please find a permit sign which is to be conspicuously posted at the project
site and protected from the weather.
Sincerely,
Torey K. Kouril
Environmental Analyst
Enclosures
TKK/file
cc: NYSDEC-BMHP
KP Realty of Greenport
i<WVDRK De artmentof
. A, Environmental
Conservation
NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION
Facility DEC To 1-4738-04088
PERMIT
Under the Environmental Conservation Law. 1� :!=�)
Permittee and Facility Information
Permit Issued To: Facility:
KAREN ADLER ADLER PROPERTY
2006 GULL POND LN 2006 GULL POND LN11000-35-3-12.11
GREENPORT,NY 11944 GREENPORT,NY 11944
Facility Location: in SOUTHOLD in SUF717OLK.COUNTY Village: Greenport
Facility principal Reference Point: NYTM-[-',: 722.328 NYTM-N: 4554.716
Latitude: 41*06'47.9" Longitude: 72'21'07,3"
Project Location: 2006 Gull Pond Lane, Greenport,NY 11944
Authorized Activity: Construct a new 18 foot by 46 foot swimming pool with a surrounding patio and
associated accessory structures including a 8 foot by 8 foot pool spa, planters, and various steps.
All work shall be done in strict conformance with the attached plans prepared by Platinum Site
Development Inc., last revised 06/01/2022,and stamped "NYSDEC Approved" on 07/05/2022.
Note. Based on the information you submitted,the New York State Department of Environmental
o-n-s—ervation has determined that the work shown on the above refrenced approved plans, is located
more than 100 feet from DEC regulated f�resliwater,wetlatids.,rherefot-c, no Freshwater Wetlands permit
is required pursuant to the Freshwater Wetlands Act(Article 24) and its' implementing regulations
(6NYCRR Part 663)to carry out this project.
Permit Authorizations
.......... µ.�.. .�..�...�.�.....�_..
Tidal Wetlands-Under Article 25
Permit ID 1-4738-04088/00004
New Permit Effective Date: 7/5/2022 Expiration Date: 7/4/2027
NYSDEC Approval
By acceptance of this permit,the perinittee agrees that the permit is contingent uPoll strict
compliance with the ECL,all applicable regulations, and all conditions included as part of this
permit.
Permit Administrator:KEVIN A KISPERT, Deputy Permit Administrator
Address: NYSDEC Region I Headquarters
SUNY @ Stony BrookJ50 Circle Rd
Stony Brook,NY 11790 -3409
4
7
Date
Authorized Signature: . .......
Page 1 of 6
NEWYORK Department of
4
STATE OF
OPPORTUNITY.. Environmentat
Conservation
NOTICE
i
i
Iment of Environmental Conservation (DEC) has issued
irsuant to the Environmental Conservation Law for work being
at this site. For further information regarding the nature and
ork approved and any Departmental conditions on it, contact
it Permit Administrator listed below. Please refer to the permit
)wn when contacting the DEC.
Regionai Permit Administrator
SUSAN ACKERMAN
s 1
a
NOTE: This notice is NOT a permit
/V%
NYSIF
New York State Insurance Fund PO Box 66699,Albany,NY 12206
1 nysif.com
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE (RENEWED)
.r
^"^^^^ 201369798
PLATINUM SITE DEVELOPMENT INC
286 ROUTE 109
FARMINGDALE NY 11735
SCAN TO VALIDATE
AND SUBSCRIBE
POLICYHOLDER CERTIFICATE HOLDER
PLATINUM SITE DEVELOPMENT INC TOWN OF SOUTHOLD
286 ROUTE 109 TOWN HALL ANNEX 54375
FARMINGDALE NY 11735 MAIN ROAD P.O BOX 1179
SOUTHOLD NY 11971-0959
POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE
Z2416 339-6 875217 07/01/2024 TO 07/01/2025 11/18/2024
THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE
FUND UNDER POLICY NO. 2416 339-6, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR
WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL
OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS
OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY.
IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS,
OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WESSITE AT HTTPS://WVWW.NYSIF.COM/CERTICEI TVAL.ASP.THE NEW
YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS.
THIS POLICY DOES NOT COVER CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED BY THE OFFICERS OF THE
INSURED CORPORATION.
PRESIDENT
ANTHONY LAURO
OF PLATINUM SITE DEVELOPMENT INC
( 1 OF 1 )
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE
COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER
THE COVERAGE AFFORDED BY THE POLICY.
NEW YORK STAT S7*1
NOE FUND
4
DIRECTOR,INSURANCE FUND UNDERWRITING
VALIDATION NUMBER:259700894
U-26.3
P11118=24
ATE(MMIDDIYYYY)
�`C>R "" 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 olicy(ies)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsements.
PRODUCER ME"A. Jenr.9 _Heiser ~~~µ~~~Wu FX F X
Nicholas DeVito Agency, Inc. PHONE 61 SIs ossryry
271-2 Route 25A EMAIL ennifer dvito Inc «
Mount Sinai, NY 11766 IlsuEEasrczEsznNctcovLAtE _.._. a . ..
INSURED IN ('Et B ._....�........ .......... .. ........... ... .. ................._ „.,....... ...,..,
Platinum Site Development Inc. INSURER C ... .._... _. .... ....... ....�
286 Route 109 1N utr n ...._.._.._. _.._. ..... .. _...... _. ....
Farmingdale, NY 11735-1561 rHsucT ,
INSURER F.,
COVERAGES CERTIFICATE NUMBER: 00009298-0 REVISION NUMBER: 47
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,
i EXCLUSIONS,TYPAND e FOl soIRANCE 'TIONS OF SUCH ffl1`i sIES.0 LIMITS S POLICY NUM OWN MAY VE BEEN REDUCED BY PPOD CLAIMS, LIMITS
.......ry
A X COMMERCIAL GENERAL LIABILITY Y 5099526655 8116/2024 8/16/2025 EACH OC"`CURREN(E $ 1,r()00,000
CLAIMS-MADE OCCUR .I'�R.I,,°6iwr,lri;+.(I„pw4F5R?� .... ..._....- ..1Ig000
X G.ontr�ctua�µL.�ak1.�....._ry ..... I
Cah l"L AGGREGATE LIMIT APPLIES PER:
..ry GENERAL AGGREGATE GREGAIT Y $... 2,000,000
..._
( POLICY 0
PRO- LOC PRODUCT a C,OMNOPAGG m
dEr'7 i $
AUTOMOBILE LIABILITY 7 8113/2024 8/13/2025 (OM INE $ 000
A 039941115 ll�f�� O�SINOLE�I IMIT ....w.... .........� ___., ... ..
OTHER:
ANY A BODILY INJURY(Per person) $
AOWNED UTOS ONLY X SCHEDULED BODILY INJURY(Per accident) $
,.�., AUTOS ..... . ........_.
HIRED NON-OWNED PROPERTY DAMAG. $
AUTOS ONLY AUTOS ONLY
(P(frP)rDa crgL
A " UMBRELLA LIAB .. OCCUR 6079150616 8/1612024 8/16/2025 ..EACH OCCURRENCE
t'......
AGGREc,AIE $ I,000,000
EXCESS LIAB CLAIMS-MADG ............. .. .......m.-. -. -
WORKERS COMPENSATION DED _ ... ,$;" yt $
PER OTH-
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DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
Town of Southold,Town Hall Annex 54373 Main Road,PO Box 1179,Southold,NY 11971 is included as additional insured as
required by written contract.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Town of Southold THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
Town Hall Annex 54373 Main Road ACCORDANCE WITH THE POLICY PROVISIONS.
PO Box 1179 AUTHORIZED REPRESENTATIVE
Southold, NY 11971
J-H
O 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Printed by J-H on 11/18/2024 at 11:19AM
Yo as Compensation
Workers' CERTIFICATE OF INSURANCE COVERAGE
�T�"r zt�. ww
Board NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW
completed b NY W�ww Family LeaveYbenefi WW µp� AWlicensedi �mmmmmm�wggµ a agent of that
Paid F�.__ _.ww _w _.sews_ .............._ .
mp disability and is earner or insurance carrier
ww.........g_................._.._�w.w._.._..................__....._ ..-......_..._......�.._.....
PART 1.To be co_._.._......�,..__....�wwµ.. _.w __....
1 a.Legal Name&Address of Insured Ouse street address only) �� 1 b.Business Telep
hone Number of Insured
PLATINUM SITE DEVELOPMENT INC. 516-681-0090
286 ROUTE 109
FARMINGDALE,NY 11735
1c.Federal Employer Identification Number of Insured
or Social Security Number
Work Location of Insured(Only required if coverage is specifically limited to
certain locations in New York State,i.e., Wrap-Up Policy) 201369798
2.N__......"'awd—..............E—nti. .q west-""...�M..._._..._..........—w_w�.�.e w..........., ._._ 3a.NaIne of lnsu ran ce.Car6er. _......_...........
..�..w�.__....-----_.........- .
ame and Address of Entit Re uestin Proof of Coverag
(Entity Being Listed as the Certificate Holder) ShelterPoint Life Insurance Company
Town of Southold
Town Hall Annex 54375 Main Road 3b.Policy Number of Entity Listed in Box"1 a"
DBL554365
PO Box 1179
Southold, NY 11971 3c.Policy effective period
04/18/2024 to 04/17/2026
4. Policy provides the following benefits:
0 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 ponatty of per)ury„M Zerfify that I ari an authorized representative or liccensa d,agent of the insurance carder referenced above and that the named
insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above.
Date Signed 11/18/2024 B
(Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier)
Telephone Number 516-829-8100 _� Name and Title Leston Welsh,Chief Executive Officer
IMPORTANT: If Boxes 4A and 5A are checked,and this form is signed by the insurance carrier's authorized representative or NYS
Licensed Insurance Agent of that carrier,this certificate is COMPLETE. Mail it directly to the certificate holder.
If Box 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 emailed to PAU@wcb.ny.gov or it can be mailed for
completionp Pans Acceptance Unit, PO Box 5200, Binghamton, NY 13902-5200.
PART2.To be completed by e NYS Workers'Compensation Board (only if Box 4B,4C or 5B have been checked) „W
......_ .. µµ ..... .. h........_____.. ._._..... __........
State of New York
Workers' Compensation Board
According to information maintained by the NYS Workers'Compensation Board,the above-named employer has complied with the
NYS Disability and Paid Family Leave Benefits Law(Article 9 of the Workers'Compensation Law)with respect to all of their employees.
Date Signed .. By
............ �.
(Signature of Authorized NYS Workers'Compensation Board Employee)
Telephone Number Name and Title
Please Note:Only insurance
ers
icensed to write NYS disability and
y leave
s insurance
cies and NYS licensed
agents o those insurance carriers are authorized to issue Form DB-120.paid
Insurance brokers arte NOT authorizeed to sue this form.insurance
DB-120.1 (12-21) 1111111111111° °°11°1°1111111°°11111°°��'1111111
Additional Instructions for Form D13-120.1
By signing this farm, 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 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 farm 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 Laid 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 Maid 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