HomeMy WebLinkAbout51639-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#: 51639 Date: 02/12/2025
Permission is hereby granted to:
Nicholas A Coutts
380 Deer Dr
Mattituck, NY 11952
To:
Install in-ground swimming pool at existing single family dwelling as applied for,with Trustees#10650
and DEC"N.J." letter.
Premises Located at:
380 Deer Dr, Mattituck, NY 11952
SCTM# 114.-10-3
Pursuant to application dated 12/20/2024 and approved by the Building Inspector.
To expire on 02/12/2027.
Contractors:
Required Inspections:
Fees:
SWIMMING POOLS-IN-GROUND WITH FENCE ENCLOSURE $300.00
CO Swimming Pool $100.00
Total $400.00
Building Inspector
TOWN OF SOUTHOLD—BUILDING DEPARTMENT
Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959
p g Telephone (631) 765-1802 Fax(631) 765-9502 httt)s://www. outlioldtowmiv.go r
N'4N b`p1;
Date Received
APPLICATION FOR BUILDING II
For Office Use Only
PERMIT NO. ?J
1
Building Inspector:r DECy n , 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.
r,
Date: J'k llo
OWNER(S)OF PROPERTY:
Name:&VJ �- ��1�. M CA40(9 oli ftS =CTM
#1000- l l U
Project Address: ?,f� Duk DY m a l( vck—1 N)l
Phone#:(p?,I ';-H'''(Sty 1 (03( '�'1 Email: �U hiLl�►ula5 C� '� .COwl
Mailing Address:
CONTACT PERSON:
Name: [;P't 060VL
Mailing Address:
Phone#: Email:
DESIGN PROFESSIONAL INFORMATION:
Name: PI A
Mailing Address:
Phone#: Email:
CONTRACTOR INFORMATION:
I
Name: W0fK^2 '5i- MASOVI N 4 LandSGG fA nit.
Mailing Address: Pp <
Phone#: lo�) 3 �6 Email:�l'l �'L► 6JIMe►-land Sca ►'n . Cowl
DESCRIPTION OF PROPOSED CONSTRUCTION
New Structure ❑Addition nAlteration ❑Repair ❑Demolition Estimated Cost of Project:
❑Other 2001 A Y +' .6 *21
Will the lot be re-graded? ❑Yes FVro Will excess fill be removed from premises? ❑Yes ❑No
1
PROPERTY INFORMATION
Existing use of property: Ve.SMUA fiGl Intended use of property: ft&-4 V0 f 1 A
Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to
p YP�
this property?e ? ❑Yes U No IF YES, PROVIDE A COPY.,rdPM�A�
Check,Box A'i"teiiIr Read : 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,mantes 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 210AS of the New York State Penal Law.
Application Submitted By(print name): gro f Q,YSQ,v, ❑Authorized Agent Owner
Signature of Applicant: Date: ZI (b 1 Ziq
STATE OF NEW YORK)
SS:
COUNTY OF SIVFM
b " being duly sworn, deposes and says that(s)he is the applicant
(Name of individual signing contract)above named,
(S)he is the w'— --
(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
C'y day of 20 2-4-
Notary Public
PROPERTY OWNER H IATPUBLIC.STATE'N W Yoft
. . „,.. Regist►ation No.01 GR8347i3
(Where the applicant is not the owner) Qualified in Suffolk County
EOM 12,
I, residing at
do hereby authorize to apply on
my behalf to the Town of Southold Ruil aepartment for approval as described herein.
Owner's Si re Date
Print Owner's Name
2
NEW YORK STATEDEPARTMENT OF ENVIRONMENTALCONSERVATION
Division of Environmental Permits,Region 1
SUNY(a Stony Brook,50 Circle Road,Stony Brook,NY 11790
P:(631)444-03651 F:(631)444-0360
www.dec.ny.gov
LETTER OF NO-JURISDICTION
May 7, 2024
Bridget Petersen
380 Deer Drive
Mattituck, NY 11952
Re: Application ID 1-4738-05011/00001
380 Deer Drive
Mattituck
SCTM # 1000-114-10-3
ARNO-DEP
Dear Applicant:
Based on the information you submitted, the New York State Department of
Environmental Conservation (DEC) has made the following determinations.
The portion of the referenced parcel landward of (above) the 10-foot elevation contour
line, as shown on the survey of the property by Nathan Taft Corwin III dated February 9,
2024, is beyond the jurisdiction of Article 25 Tidal Wetlands. Therefore, in accordance
with the current Tidal Wetlands Land Use Regulations (6 NYCRR Part 661), no permit is
required for work occurring at the property landward of(above)the jurisdictional boundary
indicated above, Please be advised however, that no construction, sedimentation,
discharge, or disturbance of any kind may take place seaward of the jurisdictional
boundary without a permit. It is your responsibility to ensure that all necessary
precautions are taken to prevent any sedimentation or other alteration or disturbance to
the ground surface or vegetation within DEC's jurisdiction which may result from your
project. Such precautions include maintaining an adequate work area (i.e., a 15' to 20'
wide construction area), or erecting a temporary silt fence, barrier, or hay bale berm. This
determination runs with the land.
DEC has documented the summer occurrence of the Northern Long Eared Bat
(NLEB) (Myotis septentrionalis), a species listed as "endangered" by both New
York State and the US Fish &Wildlife Service, within 3 miles of the project location.
We have determined that tree cutting at this location between March 1 and November 30
of any calendar year may result in the "take" of these endangered species within the
meaning of Environmental Conservation Law (ECL) §11-535. The term "take" is defined
in part as the direct killing or injury of individual members of a protected species,
interference with critical breeding, foraging, migratory or other essential behaviors, or the
adverse modification of the species' habitat. The "take" of a species listed as endangered
. N'EW YCN'R14 1 fa arNlrMtettt of
yYfY.l R,436
acagKrvoeairav fNV11"orlN7t�n'�a I
or threatened is prohibited in the absence of a permit from this Department issued
pursuant to ECL §11-535. To avoid an Endangered Species "take" or the need for an
incidental take permit, no tree cutting activities can be conducted at the project site
between the dates of March 1 and November 30 of any calendar year. If you have
questions about the presence of protected species on or near your property, the potential
effects of activities on these species or your responsibilities as a landowner or project
sponsor under the Endangered Species Regulations, please contact the Regional Wildlife
Manager at (631) 444-0310.
Please be advised that this letter does not relieve you of the responsibility of obtaining
any necessary permits or approvals from local municipalities or other agencies.
Very truly yours,
Kevin A. Kispert
Permit Administrator
KAK/mrp
C: BMHP
Wildlife
File
Glenn Goldsmith, President IrO S Town Hall Annex
$ 54375 Route 25
A. Nicholas Krupski,Vice President � P.O. Box 1179
Eric Sepenoski Southold, New York 11971
Liz Gillooly Telephone(631) 765-1892
Elizabeth Peeples Fax(631) 765-6641
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
October 4, 2024
Bridget Leigh Petersen & Nicholas Andrew Coutts
380 Deer Drive
Mattituck, NY 11952
RE 380 DEER DRIVE, MATTITUCK
SCTM# 1000-114-10-3
Dear Ms. Petersen & Mr. Coutts:
The Board of Town Trustees took the following action during its regular meeting held on
Wednesday, July 17, 2024 regarding the above matter:
WHEREAS, BRIDGET LEIGH PETERSEN & NICHOLAS ANDREW COUTTS applied
to the Southold Town Trustees for a permit under the provisions of Chapter 275 of the
Southold Town Code, the Wetland Ordinance of the Town of Southold, application
dated April 12, 2024, and,
WHEREAS, said application was referred to the Southold Town Conservation Advisory
Council and to the Local Waterfront Revitalization Program Coordinator for their findings
and recommendations, and,
WHEREAS, the LWRP Coordinator recommended that the proposed application be
found Inconsistent with the LWRP, and,
WHEREAS, the Board of Trustees has furthered Policy 6.3 of the Local Waterfront
Revitalization Program to the greatest extent possible through the imposition of the
following Best Management Practice requirements: to establish and perpetually
maintain a 10' wide non-turf buffer landward of the fence and a non-disturbance buffer
seaward of the fence; and
WHEREAS, a Public Hearing was held by the Town Trustees with respect to said
application on July 17, 2024, at which time all interested persons were given an
opportunity to be heard, and,
2
WHEREAS, the Board members have personally viewed and are familiar with the
premises in question and the surrounding area, and,
WHEREAS, the Board has considered all the testimony and documentation submitted
concerning this application, and,
WHEREAS, the project complies with the standards set forth in Chapter 275 of the
Southold Town Code,
WHEREAS, the Board has determined that the project as proposed will not affect the
health, safety and general welfare of the people of the town,
NOW THEREFORE BE IT,
RESOLVED, that for the mitigating factors and based upon the Best Management
Practice requirement imposed above, the Board of Trustees deems the action to be
Consistent with the Local Waterfront Revitalization Program pursuant to Chapter 268-5
of the Southold Town Code, and,
RESOLVED, that the Board of Trustees APPROVE the application of BRIDGET LEIGH
PETERSEN & NICHOLAS ANDREW COUTTS to construct an in-ground swimming
pool with pool patio surround, pool enclosure fencing with gates, pool drywell, and pool
equipment area; relocate existing shed 10' off of side yard property line; and to establish
and perpetually maintain a 10' wide non-turf buffer landward of the fence and a non-
disturbance buffer area seaward of the fence; with the condition that the pool be on
grade; and as depicted on the site plan prepared by Nathan Taft Corwin III, Land
Surveyor, last updated on August 22, 2024, and stamped approved on October 4, 2024.
Permit to construct and complete project will expire three years from the date the permit
is signed. Fees must be paid, if applicable, and permit issued within six months of the
date of this notification.
Inspections are required at a fee of$50.00 per inspection. (See attached schedule.)
Fees: $ 50.00
Very truly yours,
'41W_ pe<zy
Glenn Goldsmith
President, Board of Trustees
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BOARD OF SOUTHOLD TOWN TRUSTEES
1
SOUTHOLD,NEW YORK
PERMIT NO. 10650 DATE: DULY 1
a 7 2024 I
ISSUED TO: BRIDCET LEI+GH PETERSEN & NICI OLAS ANDREW COUTTS
PROPERTY ADDRESS: 380 DEER DRI B MATTITUCK
SCTM# 1000-114-10-3
AUTHORIZATION
Pursuant to the provisions of Chapter 275 of the Town Code of the Town of Southold and in
accordance with the Resolution of the Board of Trustees adopted at the meeting held on,iul� �2 , and in
consideration of application fee in the sum of tL5jL00 paid by BRIT 'iI,T LEICYIJ1_ET l SEN
i ICHwOL S NDREW COUTT'S' and subject to the Terms and Conditions as stated in the Resolution,the
Southold Town Board of Trustees authorizes and permits the following:
Wetland Permit to construct an in-ground swimming pool with pool patio surround,
pool enclosure fencing with gates, pool drywell, and pool equipment area; relocate
existing shed 10' off of side yard property line; and to establish and perpetually
maintain a 10' wide non-turf buffer landward of the fence and a non-disturbance
Irf+,G
N' buffer area seaward of the fence; with the condition that the pool be on grade; and as
depicted on the site plan prepared by Nathan Taft Corwin III,Land Surveyor, last
updated on August 22, 2024, and stamped approved on October 4,2024.
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.
,
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f� ,fd ry 'q lk rru mdV la�r�kdiwu r!�U'm «�;.Nuwm'I�'v'ww;unftr�at;icr,�'Jr�o fn`N✓'r r[u„�e l,, n�i tih,�N,tA'ur�r ti"VVla;�nr 0 r, r,+' �� m P � .
A, 1 J&9G, AI�'01!llft ku Ifou(YW
;w
w
SOUTHOLD TRU"STE- - F�s
No. 10450
g :a T P�s�cn +� eon ss
Issued To � g Date �
Address 3�� ��r brv'%/e � Aairl'-ri&GK
.THIS NOTICE MUST BE DISPLAYED DURING CONSTRUCTION
TOWN TRUSTEES OFFICE,TOWN OF SOUTHOLD
SOUTHOLD, N.Y. 11971
TEL.: 765-1892
' CERTIFICATE'IFICA 'E OF LIABILITY INSU DICE DATE@AMNDIYYYIf)
12116/2024
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 cortifloate holder Is an ADDITIONAL INSURED,the pollcy(les)must have ADDITIONAL INSURED provisions or be endorsed.
ff SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on
this cerdlIcate does not confer rights to the certillicate holder In lieu of such a risen .
PRODUCER MIIeW CIB,I
Farris Family Insurance PHONE . 631-744-3350 FAX 631-7"-3383
85 Echo Ave-$u"Ite 2 AD maitt.dal ernn- m8 rn PA.Hai
INSURE s AFFORDING COVERAGE "CO
Miller Place NY 11764 INBURERA: Farm Family Casualty Insurance Co. 13803
INSURED INSURER a: United Farm Family Casua Insurance Co. 20363
North Fast Masonry&Landscaping Inc INSURER c: Shefterpoint 81434
PO BOX 1404 INN RR D
[NeuRER E
East Qu2gue NY 11942 VMM F:
COVERAGES CERTIFICATE NUMBER. REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMIT$SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
ADOLSUOR
IN R TYPE OFINSURANCE NUMBER EFP LIMITS
LI EXP
A X ComMERcIALeENERALwaiLITY 31o2xos84 01/10/202a 01/10/2025 EACH OCCURRENCE s 10001000
01/10/2025 01/10/2026
CLAIMS-MADE RI OCCUR PRI�AI
MED EXP Iftone person) $ 5,000
PERSONAL BADVINJURY $ 1,0001000
mt AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
POLICY JECTT LOC PRODUCTS-COMPIOP AGG S 2,000,000
OTHER S
B AUTOMOBLEUABILR EeY 310105162 0//1012024 01/10/2025 _ $ 1,000,000
ANY AUTO 01/10/2025 01/10/2026 ,BODILY INJURY(Per person)
OWNED SCHEDULED BODILY INJURY(Per soWeno $
*� AUTOS ONLY+^� HIRED
ONLY AUTOS S
ONLY
R
UMBRELLALUI3 OCCUR EACH OCCURRENCE $
EXCESS LIAR CLAIMSMADE AGGREGATE E
DED RETENTION1
B WORKERS COMPENSATION 3103W6932 01/10/2024 01/10/2025 X ATRUM OTH-
AND EMPLOYERS'LUUNLnY YIN 01/10/2026 01/10/2026
ANYPROPRIETORIPARTNERimmc nVE � E.L.EACH ACCIDENT $ 100,01)0
OFFICERIMEMBEREXCLUDED7 F _.I NIA
(rAendetory In NH) E.L DISEASE-EA EMPLOYEE S 100,000
If S RrPTIONo w OPERATIONS below E.L.DISEASE-POLICY LIMB $ 500,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,AdftorW Rwaft SeMdula,maybe adecrrad If more spas la r"ulred)
Masonry& Landscape
CERTIFICATE HOLDER CANCELLATION
Town Of Southold SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Building Department THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
54375 Main Rd ACCORDANCE WITH THE POLICY PROVISIONS.
Southold NY 11971 AUTHORIM SENTATIVE
0 1988 2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD
<NTEW
RWorkers' CERTIFICATE OF
A Compensation
Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE
1a. Legal Name&Address of Insured (use street address 1b. Business Telephone Number of Insured
only) (631)594-3760
Work Location of Insured (Only required if coverage is
specifically limited to certain locations in New York State, lc. NYS Unemployment Insurance Employer Registration
i.e., a Wrap-Up Policy) Number of Insured
NORTH EAST MASONRY&LANDSCAPING INC 1d. Federal Employer Identification Number of Insured or
PO BOX 1404 Social Security Number:
EAST QUOGUE,NY 11942 27-1010867
2. Name and Address of Entity Requesting Proof of 3a. Name of Insurance Carrier
Coverage United Farm Family Casualty Insurance Co.
(Entity Being Listed as the Certificate Holder)
3b. Policy Number of Entity Listed in Box if la
Town Of Southold 3103W6932
Building Department
54375 Main Rd 3c. Policy effective period
Southold NY 11971 01/ 0/2024 to 01 10 2025
3d. The Proprietor, Partners or Executive Officers are
o included. (Only check box if all partners/officers included)
o all excluded or certain partners/officers excluded.
This certifies that the Insurance carrier indicated above in box"3"insures the business referenced above in box"la"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".
Will the carrier notify the certificate holder within 10 days of a policy being cancelled for non-payment of premium or within 30 days if cancelled for
any other reason or if the insured Is otherwise eliminated from the coverage indicated on this certificate prior to the end of
the policy effective period? XJYES []NO
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,1 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: Mat hew Dale
(Print name of authorized representative or licensed agent of insurance carrier)
Approved by: December 16, 2024
(Signature) (Date)
Title: A ent
Telephone Number of authorized representative or licensed agent of insurance carrier: 631-74 -3' '50
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(9-15) www.wcb.ny.gov
Workers' Compensation Law
Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured.
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.
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(9-15)REVERSE
Y � Workers' CERTIFICATE OF INSURANCE COVERAGE
� sTATr Compensation
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
Is.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured
NORTH EAST MASONRY&LANDSCAPING INC 631-255-4518
149 MALLOY DRIVE
EAST OUOGUE,NY 11942
1c.Federal Employer Identification Number of Insured
Work Location of Insured(only required If coverage is spedficallyhmited to or Social Security Number
certain locations In New York State,Le.,wrap-Up Policy) 271010867
2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier
(Entity Being Listed as the Certificate Holder) ShelterPoint Life Insurance Company
Town Of Southold
Building Department 3b.Policy Number of Entity Listed in Box"Is"
54375 Main Rd DBL529100
Southold NY 11971 3c.Policy effective period
03/13/2024 to 03/12/2026
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 R penury,I cRW, that I am an a repiresentative or licensed agent of the insurance 4wer refs at ve anj that the named
insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above.
Date Signed 12M 6/2024 By /4a=4�
(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 4B,4C or 5B is checked,this certificate is NOT COMPLETE for purposes of Section 220, Subd.8 of the NYS
Disability and Paid Family Leave Benefits Law. It must be emailed to PAU@wcb.ny.gov or it can be mailed for
completion to the Workers`Compensation Board, Plans Acceptance Unit,PO Box 5200,Binghamton,NY 13902-5200,
PART 2.To be completed by the NYS Workers'Compensation Board(only if Box 4113,4C or 5B have been checked)
State of New York
Workers' Compensation Board
According to information maintained by the NYS Workers'Compensation Board,the above-named employer has 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 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.
oB-1120.1 (12-21) II IIN r1 2i iu�(� � N ®�� I
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