HomeMy WebLinkAbout46003-Z o�Suffei�.co TOWN OF SOUTHOLD
BUILDING DEPARTMENT
x TOWN CLERK'S OFFICE
o . A? 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#: 46003 Date: 3/30/2021
Permission is hereby granted to:
Baranowski LA Rev tiv Trt
477 E 16th St
Brooklyn, NY 11226
To: demolish existing swimming pool and construct a new accessory in-ground swimming
pool with a spa as applied for.
At premises located at: � a� �_ vo
t2700 Fairwa Dr., Cutcho ue
SCTM #473889 NO &pnstY(Aci-:e_d
Sec/Block/Lot# 109.-5-14.13
Pursuant to application dated 3/9/2021 and approved by the Building Inspector.
To expire on 9/29/2022..
Fees:
SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00
CO- SWIMMING POOL $50.00
Total: $300.00
Buil g Inspector
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FIELD INSPECTION REPORT DATE COMMENTS
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FOUNDATION(1ST)
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'FOUNDATION (2ND)
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ROUGH FRAMING& y C
PLUMBING .
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INSULATION PER N.Y: y
STATE ENERGY CODE
FINAL
7rADDVrIONA COMMENTS
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S.C.T.M. NO. DISTRICT: 1000 SECTION:109 BLOCK: 5 LOT(S):14.13 I I FAIRWAYDRWE
LOT 12
0.2'N S 89°12'10 E CHAINLINx FENCE I2mEERGR011fLN�p
D.1•NJ 22S.59 uranEs
$ ISO
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- 05.1• - I
n SUE Pt W
8.9' PSPA'E Icy
LOT 13 >'E 1 112 m 9.0'° I (�
bo m FRAMEDWELLIN
4BEDROOM G m PAVER WALK
127M
gas• 69.4'
GARAGE i.a• _
x x x x
2.0'E g
X 655• ge� Fy
015AB96V id
X 35.7' INGROUND X BELL.6-CURB
W POOL PAYEp
F I X ASPHALT OR.,
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J.5•N X XHAINLINN FENCE J.4'N
x x x x
N 89'12'10"W LOT 14 225.59'
I
THE WATER SUPPLY, WELLS,DRYWELLS AND CESSPOOL
LOCA77ONS SHOWN ARE FROM FIELD OBSERVATIONS
AND OR DATA OBTAINED FROM OTHERS.
AREA:40,606.20 SQ.FT. or 0.93 ACRES a£vaRON DATUM:
UNAU THOR12E0 AL TERATKw OR ADDITION TO ftS SURVEY IS A VIOLATION OF SECRON 7209 OF DYE NEW YORK STAR EWCAT/W LAW. COPIES OF IS
SURVEY
MAP NOT BEARING THE LAND SURVEYOR'S EMBOSSED SEAL SHALL NOT BE CWSIDEREO TO BE A VALID TRUE COPY. GUARANTEES INDICATED HEREON SHALL RUN
ONLY TO THE PERSON FOR WHOM ME SURVEY IS PREPARED AND ON HIS BEHALF TO THE TIRE COMPANY,GOVERNMENTAL AGENCY AND LENDING INSTITUTION
LISTED HEREON,AND 70 THE ASSIGNEES OF THE LENDING INSTITUTION,GUARANTEES ARE NOT TRANSFERABLE.
ME OFFSETS OR DMEI SHOKM HEREON FROM THE PROPERTY LINES TO WE STRUCTURES ARE FOR A SPECIFIC PURPOSE AND USE THEREFORE THEY ARE
Nor INTENDED TO MONUMENT WE PROPERTY LINES OR TO GUIDE THE ERECTION OF FENCES ADDIDONAL STRUCTURES OR AND OTHER IMPROVEMENTS EASEMENTS
AND/OR SUBSURFACE SMUCNRES RECORDED OR UNRECORDED ARE NOT GUARANTEED UNLESS PHYSK'ALLY EVIDENT W ME PREMISES AT WE DIME Or SURVEY
SURVEY OF:LOT 13 SCOFNEIy11 CERTIFIED TO:KEVIN B.FEENEY; KELLY FEENEY:
NAP OF:FAIRWAY FARMS A,, AM M w,A0 FIDELITY NATIONAL TITLE INSURANCE COMPANY;
FILED: FEB. 15.1974 No.6066 *W2 Tc (p74 04-01 5 32 2)
STUATED AT: CUTCHOGUE
TowN oF:SOUTHOLD 4' KENNETH M WOYCHUK LAND SURVEYING, PLLC
SUFFOLK COUNTY, NEW YORK ZS °50e91 JQJ Professional Iand Surveying and Design
P.O.Box 153 Aquebogue,New York 11931
FLE®221-112 SCALE:1"=30 DATE:NOV.09,2022 N.Y.S.USC.NO.050882 PHONE(631)29B-1508 TAX(631)296-1589
=�O��gUFF01K�oGy� TOWN OF SOUTHOLD—BUILDING DEPARTMENT
N Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959
oy o�g Telephone (631) 765-1802 Fax (631) 765-9502 https://www.southoldtownny.izov
col
Date Received
APPLICATION FOR BUILDING PERMIT -' -
i
or Office Use Only �', �",,r
MAR 9 2021
PERMIT NO. V Building Inspector:
Applications and forms must be filled out in their entirety. Incomplete r
applications will not,be accepted. Where the Applicant is not the owner,an -
Owner's Authorization form(Page 2)shall be completed.
Date:
OWNER(S)OF PROPERTY:
Name: SCTM #1000-
Project Address:
Phone#: Email. r
Mailing Address:
CONTACT PERSON:
Name: \\ rr
---- -- V_ - .'M 0-Qv�Q----------- -- - ---
Mailing Address:
---- . -- - - o - - -
Phone#: Email:
DESIGN PROFESSIONAL INFORMATION:
Name:
Mailing Address: X
Phone#: }o Email:
CONTRACTOR INFORMATION:
Name:
Mailing Address: 1`j q _�o-- - --- - -
Phone#: Email:
DESCRIPTION OF PROPOSED CONSTRUCTION
❑New Structure ❑Addition ❑Alteration ❑Repair, emolition Estimated Cost of Project:
Other 1g-1Sn /60� 00 O
Will the lot be re-graded?Pes ❑No Will excess fill be removed from premises? ❑Yes fr=mo
1
PROPERTY INFORMATION
Existing use of property: Intended use of property:
Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to
this property? ❑Yes El No IF YES, PROVIDE A COPY.
qCCheck BoxAfter Reading: The owner/contractor/design professional is responsible for all drainage and storm water issues as provided by
pter 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): 4 Authorized Agent ❑Owner
Signature of Applicant: ---Date: --��' eL
STATE OF NEW YORK)
SS:
COUNTY OF
"�ILU V Y nn,� `� 4 J being duly sworn,deposes and says that(s)he is the applicant
(Name of individual signing contract)above named,
(S)he is the �.U�1�r�t
(ContractorQAgent,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 he application file therewith.
Sworn before me this
day of 202-1
Notary Pfiblic
PROPERTY OWNER AUTHORIZATION TIANAAGAINES
NOTARY PUBLIC,STATE OF NEW YORK
(Where the applicant is not the owner) Registration No.OIGA6392254
Qualified In Suffolk County
Commission Expires May 20,2023
I, residing at
do hereby authorize to apply on
my behalf to the Town of Southold Building Department for approval as described herein.
Owner's Signature Date
Print Owner's Name
2
Building Department Application
AUTHORIZATION
(Where the Applicant is not the Owner)
L_Lt l n 150-r to o L..)S k,- residing at (9-it0 F J rwM f
(Print property owner's name) (Mailing Address)
-CiIT�Ti���t N q I 19 35- do hereby authorize V' /rl 0/'
(Agent)
to apply on my behalf to the
Southold Building Department.
(Owner's Signa (Date)
(PAnt Owner's Name)
5URVEY No. 513NY-20-4655 MAP OF FAIRWAY FARMS DATE: OCTOBER 8th, 2020
PREPARED BY RAJ KUMAK TOWN OF 5OUTHOLD
DRAWN BY: T.W. COUNTY OF 5UFFOLK
5TATE OF NEW YORK
D15TPJCT 1000 5ECTION 109.00 BLOCK 05.00 LOT 014.013
TH15 5URVEY WA5 PREPARED FOR LYN ALY55A BARANOW5KI AND 15 TO BE U5ED FOR TITLE PURP05E5 ONLY
NOW OF FORMERLY ONE z
NORTH FORK COUNTRY CLUB
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TITLE No. ON I W ENTfllEV'iMAF OF FAIRWAY FARMS'
AMB20-75 1 195 FILED ON FEBRUARY 15th. 1974 AS MAP No 6066
CERTIFIED TO:
LYN ALY55A BARANOW5KI
WE5TCOR LAND TITLE IN5URANCE COMPANY LI co!
AMBA5ADOK AB5TRACT, LLC
11 �
.uARA a=OR CEKnnCATIOm5 INDICATED nEREaI SMALL RUN ONLY TO THE PERSal FM WHOM Tnt 5URM
6 PREPARED AND ON THEIR BEHALF TO THE TITLE COVPANY,GOVERNMENTAL AGENCY AND LENDING IN571ITLIT101/
Lr,TED HEREON AND TO THE AS9IGNEE5 Of THE LENDING INSTMAION.GtaARN(TEE3 OR aRTIflCAT10N5 ARE NOT ! r/
TRAN5feRA5LE TO ADOMONAL INSTTTUTION5 OR 5LIMEOLIENT OWNERS,
3. MOR1ZE0 ALTERAA1NLO�II O ADDDITIO TTOOT�5DSUURR�15 Af VIOtLAT HIS OR OF SECTION 7209 or THE New YnRY. 5 B O RO MAPPING
STATE EDLICAT10-1 LAW 966 LITTLE NECK AVENUE NORTH
4 ONLY COrMS fROM THE ORIGINAL Of THIS SURVEY MAR/ED WITH AN ORWNLIL OF THE LAND SURVEYOR5 INFID
SEAL OR HIS EIu ao%eb SEAL SMALL 5E CONSIDERED TO BE VAUD T"COMES BELLMORE N.Y. 1 1710 'N,
5 EASGJENTS Of RECORD ARE ONLY GMARIUITEED If All AWTRACT Of TITtf 15 fMR *nW TO THE SuRVEYDR
C ln15 Ls TO GERTIrr TnAT THERE ARE NO Vt3iBtL sTREAM9 tIOR NATURAL WATCRC011RSE5 nl TMt PROPERTY TELEPHONE (516)-652 9984 vINGENY TEL}tONIGO, L.S
EXCEPT AS show►,ON THIS SURVEY EMAIL: 5boromappingQgmail.com NEW YORK LICENSE 050307
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AP ROVED AS NOTED
DATE a Bp;#
FEE: BY-
NOTIFY BUILDING DEPARTMENT AT .
765-1802 8 AM TC 4 PM FOR THE RETAIN STORM WATER RUNOFF
;=oL LOWING INSPECTIONS: PURSUANT TO CHAPTER 236
i. FOUNDATION — TWO REQUIRED
� OF THE TOWN CODE.
FOR POURED C :� cCRETE
2. ROUGH - FRAM,,,l & PLUMBING
3. INSULATION
4. FINAL — CONSTRUCTION MUST
BE COMPLETE
ALL CONSTRUCTICAi SyALL MEET THE
REQUIREMENTS OF THE CODES OF NEW
YORK STATE. NOT RESPONSIBLE FOR
DESIGN OR CONSTRUCTION ERRORS.
ELECTRICAL
INSPECTION REQUIRED
COMPLY WITH ALL CODES OF
NEW YORK STATE & TOWN CODES
AS REQUIRED AND CONDITIONS OF
Off EAWNG3,0ARD
Q EOI r,T TR►I TEES
"IMMEDIATELY,.
ENCLOSE POOL TO CODE
-
=_.UPON COMPLETION
BEFORE "WATER"—
OCCUPANCY OR
USE IS UNLAWFUL
WITHOUT CERTIFICAT,
OF OCCUPANCY
._j J
L'
ALL
MENSIONS
1 " TO WASTE ARE TO BEI FIELD VERIFIED
HAIR & LINT NOT IUB ir x g 01 50'-0" 01
STRAINER 77�iTIa�NYC
PUMP p COUNTY OF SUFFOLK
FILTER AUTO SKIMMER 10,eEAM I to'BEAM STATE OF NEW YORK
RERIRN
DUAL MMN DRNN DUAL MAIN DRAgi 11
BACK TO POOL YA H STRPJ� ""ii STRARM
APPRWE DRAM) AP�PR M DRDRErfAPA7S�
POOL o o
AM COM Box (B Fr.) 20' X 50' POOL (4 F.) f AVID COM Bax 20' X 50' POOL f
'0 11 O
® N m7m N All Draeing%Speciftatims end
the design espresesd therein ore
the ode property or AM
I. Engineering,P.C.They"to be
used only with h respect to tile
DUAL MAIN DRAIN WITH TProject erw ere not to be copied
f1 PUMP LRiiT es�,,, off A� g,
HYDROSTATIC VALVE AND � 50 -O �, �_--'°
COLLECTION TUBE IN GRAVEL BASE
ALL CORNERS FORMED BY
DROME M OF WAILS AND
FLOOR SNAIL BE DRDUNIM
ImIm Mr.
SCHEMATIC PIPING ARRANGEMENT POOL PLAN POOL PLAN
N.T.S. N.T.S. N.T.S.
POOL NOTES: Ism
FOR POOLS CONSTRUCTED ON VIRGIN SOIL, 1. POOL AND PROPERTY TO CONFORM TO NYS 2020 UNIFORM CODE SUPPLEMENT SECTION R326 %E OF NE(N
COMPACT BASE TO 95% MODIFIED �P EW S e 0
PROCTOR. FOR POOLS CONSTRUCTED ON 2.POOL SHALL CONFORM TO ANSI/ NSPI STANDARDS R326.3.1. �a� RyG
BACKFILL MATERIAL, POOL CONTRACTOR TO 3.SECTION R326.7 POOL ALARM REQUIRED.
INSTALL 6" COMPACTED GRAVEL BASE
4.ENTRAPMENT PROTECTION REQUIRED SECTION R326.5.
POOL RETURNS SET AT 5.POOL SHALL COMPLY %MTH BARRIER REQUIREMENTS SECTION R326.5. m cu
* 12" BELOW WATER LEVEL REINFORECED GUNITE 2 „� 2-11-21
" WATER 6.POOL SHALL COMPLY WITH INTERNATIONAL ENERGY CONSERVATION CODE SECTION R403.10: cP C� No
SEE P AN #4 ® 10 O.C. EACH WAYLINE �O 0774'39
wmvm BY I Cs
LO �p 00 o 0 o POOLS AND PERMANENT SPA ENERGY CONSUMPTION (MANDATORY), AROFESSIONP�
I I I p RADIUS SECTION R403.10.1 HEATERS /A�
LO I SECTION R403.10.2 TIME SWITCHES
n 1:7 MAX n
00 1924 Bdlmare Avenue
8 THICK 10 THICK SECTION R403.10.3 COVERS Bellmo%New York 117f0
FLOOR _SSLOPE WALL Phona(516)785-42W
1:3 MA 7.THE DESIGN IS BASED ON A DRAINAGE SOIL WITH <10% SILT, GROUND WATER SHALL NOT EXIST WITHIN LIMITS OF THE EXCAVATION. IF Fax (516)785-814e
LOP ANTI VORTEX GROUND WATER EXISTS WITHIN 6' BELOW GRADE SPECIAL DEWATERING FACILITIES WILL BE REQUIRED. WATER DISPOSAL IS LIMITED TO
#4 BARS ® 10" O.C. PLACED ANTI ENTRAPMENT BEAU
THORUGHOUT POOL BOTH VGB COMPLIANT OWNER'S PROPERTY.
HORIZONTALLY AND MAIN DRAIN COVER
VERTICALLY GRAVEL HYDROSTATIC 8.NO SURCHARGE ALLOWED WITHIN 4' OF SHALLOW END AND 6' OF DEEP END.
SUMP RELIEF VALVE 9,THE PNEUMATICALLY APPLIED CONCRETE (GUNITE) SHALL BE 4,000 PSI 0 28 DAYS. U0 on4sg
DOUBLE MAIN DRAIN 0 W.P. Rr Imo
SPACED 3'-0" APART 10. REINFORCING STEEL SHALL BE INTERMEDIATE GRADE BILLET STEEL WITH A MINIMUM LAP OF 30 BAR DIAMETERS. 04
PER CODE 11. REBAR SHALL BE 2' MIN. CLEAR TO EARTH. DAWINQ
POOL DIMENSIONS AND FACILITIES SHAL CONFORM 12. POOL WATER SUPPLY BY OWNERS GARDEN HOSE. POOL TO BE KEPT FULL DURING FREEZING WEATHER. PUMP CAPACITY TO BE POOL PLAN,
WITH THE REQUIREMENT FOR A TYPE 1 POOL SUFFICIENT TO EMPTY POOL IN 24 HOURS. CROSS SECTION &
13. LOCATION OF PROPOSED SWIMMING POOL AND POOL EQUIPMENT BY OTHERS AND SHALL COMPLY WITH ALL LOCAL ZONING PIPING SCHEMATIC
CROSS SECTION "A" REQUIREMENTS.
N.T.S. 14. ALL DRAIN COVERS TO MEET ALL REQUIREMENTS OF THE VIRGINIA GRAEME BARKER (VGB) POOL AND SPA SAFETY ACT. PRMCP
15. THE SWIMMING POOL HAS NOT BEEN DESIGNED FOR USE WITH DIVING EQUIPMENT, FOR DECK LEVEL DIVING BOARD REFER TO ANSI/ PROPOSED GUNITE
APSP/ ICC-5 2011 REQUIREMENTS FOR MINIMUM POOL DEPTH AND INTERIOR POOL DIMENSIONS. IN—GROUND POOL
16. CONTRACTOR SHALL VERIFY SOIL BEARING LOADS PRIOR TO INSTALLATION OF POOL
17. SLOPE PATIO SURFACE 9' PER FOOT AWAY FROM POOL 0.
AQ- 1
6
ALL DIMENSIONS
ARE TO BE FIELD VERIFIED
CEMENT MORTAR JOINT " 10' Minimum Length of Non 6"x6" FROST PROOF
r „ 4 2 STANDARD Metallic Conduit with 8 insulated TILE OR MOSAIC 1700 FAIRVIEW AVE.
1l 2 COPING copper wire as per NEC COPING PARRERN BORDER SOUTHOLD. NY
Brass Electric Pull
COPING Boxes 6" Above Water " #8 GROUND COUNTY OF SUF OLK
2-#4 BARS 4 2 WIRE TO STEEL STATE OF NEW YORK
2-#4 BARS 2-#4
�� BARS I
BORDER c0
BENT BOND cV Jz" BRAS I LL
PLASTER BEAM AROUND 4" Mi CV 111 NITCH #4 BARS ® RECESSED12" O.C. LIGHT AD Drawings.Sp.dlloetione and
-PLAN BOTH WAYS the�•- theSECTION " f„gtnowngg,,P GyTh�to be
#4 Bars ® 12 OCueed only w8h respect tothb
11 SKIMMER NITCH DETAIL Horizontal and "9��are not to be�hd
Typical Light Box Detail Vertical aEngineering.
Coping N.T.S. YP 9 Typical Section At Spa Vic"
N.T.S. N.T.S. N.T.S.
COPING COPING 6x6 Frostproor
Tile
�'t2-#4 BA 6x6 FROST Number of
Steps as
SWIMOUT PROOF TILE 2-#4 needed to
BARS suit pool(0 _
de th
#4 Bars p I OF NEW 1
#4 Bars' ® ® 12" OC See Pool Pla M b- REW g,e Oro
12 OC for length of
pool steps Q
RADIUS VARIES
SEE SCHEDULE #4 Bars ® n
12 OCCS
Typical Section At Shallow End N�a °
Typical Section At Swimout N.T.S. ,oR �?7439 ��'� AS
.5
N.T.S. OFES S I01A
1924 Bellmore Avenue
COPING Bellmore,Now York 11710
Phanc(510795-4200
" " Bond Beam Steel 2-#4 SLOPE DECK Fcw (516)785-9148
6 x6 FROST PROOF For Non Expansive Soil Y /FT SU.
TILE OR MOSAIC 3-#4 For Expansive Soil
PATTERN BORDER
WATER LINE " C
'17MI'Al RADIUS SCHEDULE C 0774�
S MAUM.P.E
024 BaLMOR A�enU.M ra rrno
#4 Bars 1 0. 10" THICK 0 FT 6 FT 6 FT Poa DEPTH RADIUS
Hor z n n e l a WALL °RAM'"
1 FT 6 FT 6 FT S-6' 1'-0'
4'-0' 1'-0'
2 FT 6 FT 6 FT 4'-8' 1'-6'
5'-0' 1'-6• POOL DETAILS
3 FT 6 FT 6 FT 5'-8' 2'-0'
6'-0' 2'-8'
Anti Vortex 4 FT 6 FT 6 FT 6'-0' S-o'
Anti Entrapment IC 7'-0' 3'-6'
Main Drain Cover ALL THICKNESS TO 5 FT 6 FT 6 FT 7'-7' 4-0'
BE CHANGED UNIFORMLY 8'-0' 4-6'
6 FT 6 FT 7 FT W-r 5'-0'
" 9•-0' s'-o' PROPOSED GUNITE
#4 Bars ® 10 O.C. IN-GROUND POOL
MAIN DRAIN Horizontal and 7 FT 8 FT 9 FT w-6' 5'-0'
10'—B' 5'-0'
VGBA COMPLIANT Vertical 8 FT 9XFT 9 FT
a
Typical Section At Deep End s FT 11 FT 11 FT
N.T.S. AQ—2DI
NYSI F
New York State insurance Fund 8 CORPORATE CENTER DR,3RD FLR,MELVILLE,NEW YORK 11747-3129
nysif.com
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE (RENEWED)
n n n n n n 455296491
MALONEY&MALONEY INC %w".
108 WEST MONTAUK HIGHWAY
PO BOX 1024
HAMPTON�AYS NY 11946 SCAN TO VALIDATE
i
AND SUBSCRIBE
POLICYHbLDER CERTIFICATE HOLDER
M&M Pi LLC TOWN OF SOUTHOLD
PO BOX1302 . BUILDING.DEPT
HAMPTON BAYS NY 11946 54375 ROUTE 25
SOUTHOLD NY 11971
POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE
1210i0 482-5 2825 05/06/2020 TO 05/06/2021 12/28/2020
THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE
FUND UNDER POLICY NO. 2100 482-5, 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.
i
IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS,
OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTPS://WWW.NYSIF.COM/CERTICERTVAL.ASP.THE NEW
YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS.
THIS POLICY DOES NOT COVER THE SOLE PROPRIETOR,PARTNERS AND/OR MEMBERS OF A LIMITED LIABILITY COMPANY.
THE POLICY INCLUDES A WAIVER OF SUBROGATION ENDORSEMENT UNDER WHICH_NYSIF AGREES TO WAIVE ITS RIGHT
OF SUBROGATION TO BRING AN ACTION AGAINST THE CERTIFICATE HOLDER TO RECOVER AMOUNTS WE PAID IN
WORKERS':.COMPENSATION AND/OR MEDICAL BENEFITS TO OR ON BEHALF OF AN EMPLOYEE OF OUR INSURED IN THE
EVENT THAT, PRIOR TO THE DATE OF THE ACCIDENT, THE CERTIFICATE HOLDER HAS ENTERED INTO A WRITTEN
CONTRACT;WITH OUR INSURED THAT REQUIRES THAT SUCH RIGHT OF SUBROGATION BE WAIVED.
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.
i
NEW YORK STATE INSURANCE FUND
DIRECTOR,INSURANCE FUND UNDERWRITING
VALIDATION NUMBER:850323817
U-26.3