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HomeMy WebLinkAbout32484-ZFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEP~RTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY No: Z-33344 10/21/08 THIS CERTIFIES that the building ACCESSORY Location of Property: 705 GUS DR (HOUSE NO.) (STREET) Co%unty Taxx ~ap NO. 473889 Section 38 Block 7 Subdivision Filed Map No. __ Lot No. __ EAST MARION ( HAMLET ) LOt 10.17 conforms substantially to the Application for Building Permit heretofore filed in this office dated NOVEMBER 13, 2006 pursuant to which Building Permit No. 32484-Z dated NOVEMBER 13, 2006 was issued, and conforms to all of the requirements of the applicable provisions of the law. The occupancy for which this certificate is issued is ACCESSORY IN GROUND SWIMMING POOL WITH FENCE TO CODE AS APPLIED FOR. The certificate is issued to REALTY CORP GUSMAR (OWNER) of the aforesaid building. SUFFOI~K CO~DEPARTIWENT OF ~L~LTHAPPRO%L~L N/A EI~L-rKICAL C~RTIFICATE NO. 4042 12/02/06 ~LU~ERS CERTIFICATION DATED N/A Rev. 1/81 Farm Ho~ 6 TOV~ OF SOUTHOLD BUILDING DEPARTMENT TOWN H~LL "/6~-1802 APPLICATION FOR CF-,I~"I"~II~ICA31'F-, OF OCCUP._AN~Y This application mu~t be filled in by typownter or ink and submiued to the Buildi~--Depa ..n'lnent w~th.the foilo~mg. A. For new btlllding or new use: 1. Final survey of property with accurate location of all buildings, property lines, streets, and unusual natural or · topographic feature~. 2, Final Approval from Health Dept. of water supply and sewerage-disposal (3-9 form). 3. Approval of electrical instaliatinn from Board of Fire Uuderwriters. 4. Sworn statement from plumber certifying that the solder used in- system contains less than 2Y I 0 of 1% lead. ,~. Commercial building, induswi'a{ building, multiple r~idence~ and similar buildings and installations, a cerfiticate of Code Complianeo from ardhitect or engineer respnnsihle for the building. 6. Submit Planning Boant Approval of completed mite plan requkemants. B. For existing buildings (prior to April 9, 1957) uon-colmforming us~s, or buildings sad "pta-existing" land uses: 1. Accurate survey o f prope, rty showin{ ail properly lines, streets, building and unusual natural or topoiraphic fealurcs. 2. A properly Comple~exi application and consent to Inap~c! siam'led by tho applicant. It' a C,~;ificate of Occupancy is denied{ the Building Inspector shall state the rusona therefor in wdtin~ to the appiicani. C. Fccs I. Certificate of Occupancy - N~v dwdllng $25.00, AddRious to dwelling $25.00, Alterations to dwelling $25,00, Swimming pool $25.00, Acc~sory building $25.00, Additions to accessory building $25,00, Businesses $50,00. 2. Certificate of Occupanoy on Pre-existing Building - $100.00 3. Copy of Certificate of Occupancy - $,25 4. Updated Cer~ifi~te of Occupancy- $50.00 , 5. Tempcrsry Ccrhficate of Occupancy - Residential $11i.00, Commurcial $15.00 Date. New Construction: .~ Old or Pre-existing Building: (check House No. Street Owner or Owners of Property: Suffolk Co~ty T~x Map No 1000, Section Subdivision permit Health Depl, Approval: Plans/ns Board App~ow]: R~u~ fort Date of Permit. Filed Map. Applicant: Underwriters Approval: Temporary Certificate ,, Final C~-tificate: Fee Submitted: ,.- (¢h~k one) d OLt, I-LLt, IE9 S3/0.[.S3 IINblflS doq:EO LO LO des SUFFOLK BUREAU o~ ELECTRICAL 40 Nottingham Drive, Middle Island, NY 11953 Telephone: 631 495 8136 · Fax: 631 980 6455 · E-Mail: SBEIGS@gmail.com ::~::~ Appli~nt: Bethel Ele~rical Contra~ing ::Rough In Znspe~ion Date: Z2/2/2006 Final ~nspe~ion Date: ~2/2/2006 ~ Application N°: 4042 Ce~ificate N°: 4042 ?.~: Suffolk County Tax Nap N°: 38 7 Z0.0~7 Building Permit N°: :~?: This CeKificate of Ele~ri~l Compliance is limited to the inspe~ion and compliance of ele~rical equipment :::::::'~ and/or work described below, installed by the applicant named above, located at the premise of and not a~er the final inspection date above: :.?:Owner: Gusmar ReatW Corp. ~Address: 705 Gus Drive, East Narion, NY Z~939 ~:.Add~ss of [nspe~ion Site: 705 Gus Drive, East Narion, NY ~Z939 Indoo~ Basement Se~ice Shed Commercial X Outdoom Zst Floor X Pool Other: New Renovation 2nd Floor Hot tub Addition Su~ey Affic Garage Se~ice 1~ Heat Duplex Recpt Ceiling Fix HZD Fix Se~ice 3~ I Time Clock i Switches Wall Fix Smoke Der Nain Panel Hot Water I GFCI Recpt Recessed Fix Co Der 4 Ckt Sub- Panel GFCI Breaker 1 Single Recpt Fluorescent Fix I Pump Disconnects D~er Recpt Range Recpt ~C Blower Emergency Fix Trans[ormem Exhaust Fan Appliance A/C Cond Exi~ Fix Twist Lock ~SS Heat Pump Electric Heat I Pool Luminaire Other Equipment: 1- Auto Chlorinator The ele~rical work and/or equipment described above were inspe~ed and appear to be in compliance with local, state and national ele~rical code requirements and this offi~. :::. App ~nt: Bethel Elect~l Contmc~ng Li~nse No: 2880-ME FORM NO. 3 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Hall Southold, N.Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) PERMIT NO. 32484 Z Date NOVEMBER 13, 2006 Permission is hereby granted to: REALTY CORP GUSMAR LONG ISLAND CITY,NY 11101 for : CONSTRUCTION OF AN IN-GROUND SWIMMING POOL AS APPLIED FOR at premises located at County Tax Map No. 473889 Section 038 pursuant to application dated NOVEMBER Building Inspector to expire on MAY Fee $ 150.00 705 GUS DR EAST MARION Block 0007 Lot No. 010.017 13, 2006 and approved by the 13, 2008. Rev. 5/8/02 ORIGINAL TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ [ ] FRAMING / STRAPPING [ ] FIREPLACE & CHIMNEY [ ] FIRE Si~'=EI'YINSPECTION [ ] FIRE RESISTANT CONS~UCTION [ ] FIRE RESISTANT PENETRATION DATE INSPECTOR~ TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION FOUNDATION 1ST [ ] ROUGH PLBG. FOUNDATION 2ND [ ] INSULATION FRAMING / STRAPPING [~I~NA~ FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION RRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION_ REMARKS: ~~,-~~~__ ~ ~/~-~ ,~ DATE ~ INSPECTOR ~~/~ FIELD INSPECTION REPORT ! DATE I COMMENTS FOUNDATION (1ST) FOUNDATION (2ND) ROUGH FRAMING & PLUMBING INSULATION PER N. Y. STATE ENERGY CODE ADDITIONAL COMMENTS TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, NY 11971 TEL: (631) 765-1802 FAX: (631) 765-9502 www. northfork.net/Southold/ Examined Approved Disapproved aJc /~//~ ,20 0.6 "///? ,:o Expiration ~/'T2~ , 20 O7 3 PERMIT NO. BUILDiNG PERMIT APPLICATION CHECKLIST Do you have or need the following, before applying? Board of Health 4 sets of Building Plans Planning Board approval ~ Check Septic Form N.Y.S.D.E.C. Trustees Contact: Mail to: Phone: Building Inspector APPLICATION FOR BUILDING PERMIT Date tl/~) ,2006~ INSTRUCTIONS a. This application MUST be completely filled in by typewriter or in ink and submitted to the Building Inspector with 4 sets of plans, accurate plot plan to scale. Fee according to schedule. b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public streets or areas, and waterways. c. The work covered by this application may not be commenced before issuance of Building Permit. ~ d. Upon approval of this application, the Building Inspector will issue a Building Permit to the applicant. Such a permit shall be kept on the premises available for inspection throughout the work. e. No building shall be occupied or used in whole or in part for any purpose what so ever until the Building Inspector issues a Certificate of Occupancy. f. Every building permit shall expire if the work authorized has not commenced within 12 months a~er the date of issuance or has not been completed within 18 months from such date. If no zoning amendments or other regulations affecting the property have been enacted in the interim, the Building Inspector may authorize, in writing, the extension of the permit for an addition six months. Thereafter, a new permit shall be required. 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, Suftblk County, New York, and other applicable Laws, Ordinances or Regulations, for the construction of buildings, additions, or 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 for necessary inspections. RETAIN STORM WATER ~UNOFF ~ '~,o PURSUANT TO SECTIO~ (Signature of applicant or namb, if~t,/c, ,p-orat~on' ) OF THE TOWN CODE. "IMMEDIATELY" .-5],1\ I ,20 )..7C ,' lllO ENCLOSE POOLTO CODE ALL CONSTRUCTION SHALL - (Mailing ad~tres~ ofappliiant)' uPON COMPLETI~O.N ME THE R co-nE "WATER El' EQUIREMENTS OF THE State ~01'ie' ~e' 'r ap~ficant is owner, lessee,llglSg~all¢l~W,~B~FAl~.neral contractor, electrician, ~lumber or builder -- A??Ft)VEO AS Nameofownerofpremises ~-h~tL.,~ n, xc~C- ~---~-n ( lc'-/ ,-,,,.,-~-. ti/ct/6 a~ (As on the tax roll ~)r latest d~e"c~"% ;.~,'; ....... //fl/. .cfi ..... EE' /Du- B'¢. If al;~hcant ts a corporation, szgnature of duly aukhofized ~)fficcr--~ g. ~t{: ' ' 'u ~'~ _ ~ .... t3 Il ~ I , Ih ,, ~ ~ BUILDING DE, ARTMENT AT u'~ame and Utle cz corporate omcer) , , , ~ FOLLOWING INSPECT Builders License No. Plumbers License No. Electricians License No. Other Trade's License No. OCCUPANCY OR U~E I~.UPlL~VVFUL ~AII-TU~I IT ClaTIFI AT OCCUPANCY Location of land on which proposed wlJ~lt~l~ 1. FOUNDATION - Tvo REQUIRED FOR POURED COhCRETE 2. ROUGH - FRAMING & PLUMBING 3. INSULATION 4. FINAL- CCNSI ~'7~?,'''!'I MUST BE COMPLETE i--{ Fl C.O. ALL CONSTRUCTION SHALL MEET THE ~ I~EQIJII:I.E.ME~I~TS OF I~IF~OO[~EI~ OF NBN House Number Street County Tax Map No. 1000 Subdivision ~) tv~ ~a ~ ¥ (Name) Section HamlebESIGN OR CONSTRUCTION ERRORS. Block C) '"'1 Lot lO, / 7, Filed Map No. Lot ~ 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy ~.,e:~_ . .~O' r~ ~L b. Intended use and occupancy 3. Nature of work (check which applicable): New Building_ Repair Removal Demolition 4. Estimated Cost ~ ~, ~ O 5. If dwelling, number of dwelling units \ If garage, number of cars Addition Alteration OtherWork ~o~coo ~,~ ~-7-- ' ~3 (Description) (To be paid on tiling this application) Number of dwelling units on each floor 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use. 7. Dimensions of existing structures, if any: Front Height ~ O Number of Stories Rear _Depth Dimensions of same structure with alterations or additions: Front Depth_ Height Number of Stories Rear 8. Dimensions of entire new construction: Front Rear Height Number of Stories 9. Size oflot: Front ~53 Rear ~_,{C3 Depth { '7-], 10. Date of Purchase Name of Former Owner ~- ~ ~ (- .Depth 11. Zone or use district in which premises are situated 12. Does proposed construction violate any zoning law, ordinance or regulation? YES NO/ , 13. Will lot be re-graded? YES__ NO ,/"/'Will excess fill be removed from premises? YES V" NO 14. Names of Owner of premise&("~,-o5 rv~ C ~ ~ {4~ Address Phone No. Name of Architect ~Address Phone No Name of Contractor~ ' Address Phone No. 15 a. Is this property within 100 feet of a tidal wetland or a freshwater wetland~ *YES NO * IF YES, SOUTHOLD TOWN TRUSTEES & D.E.C. PERMITS MAY BE REQUIRED. b. Is this property within 300 feet of a tidal wetland? * YES NO * IF YES, D.E.C. PERMITS MAY BE REQUIRED. 16. Provide survey, to scale, with accurate foundation plan and distances to proP .~.'~ y lines. 17. If elevation at any point on property is at 10 feet or below, must,pr.o,,~ide tqpographical da~a'(>~ sorvey.~ . ; STATE OF NEW YORK) SS: " ~..e).tt% *D vet ~ e ~ c, h4r~-{ being duly sworn, deposes and says that (s)he is the applicant (Name of individual sing 'cont}act) above named, (S)He is the (Contractor(~} Corporate Officer, etc.) of said owner or owners, and is duly authorized to perform or have performe? the said work and to make and file this application; that all statements contained in this application are tree to the best of his kn6~t~k1~g'hn~"beli~f; and that the work will be performed in the manner set forth in the application filed there2~t.h.~ ~'/.., .~ ~] [) ~ i ~ ~ J Swo$0 tq before me this h ~ ~ 7.~ &, day of ~/'1) O.~4,VI lo.P.d 200~o Not~blic * , f Appl : ,.L .' S~gnature o ,cant MELANIB DOROSKI NOTARY PUBLIC, State of New Yorl~ No. 01 D04634870 Oualified in Suftolk County-x.(,, \ ~l Oommissm Exp'~es 8eptembe[ 3~, "' · ." ~ ~0~ 'cl ~ °~Orr~rlu POOL DIMENSIONS ALL CONSTRUCTION SHALL MEET THE REQUIREMENTS OF 7HE CODES OF NEW YORK STATE~ "IMMEDIATELY" ENCLOSE POOL TO cODE uPON COMPLETION BEFORE "WATER" F OCCUPANGW UH , L I:I %USE IS UNLAWFUL F OGCUPANC .......................... 1 I NOTIFY BUiLDiNG :?~RTMENT .~T PANELSTIFFNER ~-~0~ 8AM ~0 4P;~ FORTHg FOLLOWING INSPECTIONS: 1. FOUNDATION ' TWO REQUIRED FOR POURED CONCRETE 2. ROUGH - FRAMING & PLUMBING . co.~.~ 3. iNSULATION 4. FINAL - CONo ~uCTION MUST 1 ' LONG WEL[t -- N.UUlNUMCOATINS BE COMPLETE FOR C.O. ALL CONSTRUCTION SHALL MEET THE 2O~,.~.~UN~ REQUIREMENTS OF THE CODES OF NEW S~ELW~P~eL YORK STATE. NOT RESPONSIBLE FOR ~._~,,~.,OL~.N~.(2)~N OR CONSTRUCTION ERRORS. RUBBER FULCRUM COMPLY WITH ALL CODES OF NEW YORK STATE & TOWN CODES ~ SO~ ............ k~ BOARD N.Y.S. DEC TYPICAL WALL SECTION AT 'A' FRAME A1 POOL PLAN B1 A2 B2 C2 SECTION MIN. 2' THICK VERMICULITE AGGREGATE TAMPERED D2 N~-~:5 -: ~,.~ CORNER CONNECTION DE DUNRITE POOLS, INC. 35t0 VETERANS MEMORIAL HIGHWAY BOHEMIA, NEW YORK 11718 (631) 58~1618 TYPE: RECTAGLE I REV. POOL JAMES DEERKOSKt, P.E. 260 DEER PATH MATrlTUCK, NEW YORK 11952 I S~ALE N.T.S. DATE DRAWING NUMBER OF STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1% Legal Name and address of Insured (Use street address only) Dunrite Manufacturing Corp 3510 Veterans Memorial Highway Bohemia, NY 11716 Work Location of Insured (Only required if coverage is specifically lbnited to certain locations in New York State, i.e. a Yfrap-Up Policy) 2. Name and Address of the Entity Requesting Proof of Coverage (Entity Bring Listed as the Certificate Holder) Town of Southold Building Dept Main ·Street Southold NY 11971 lb. Basi~ess Telephone Nuraber of Irk~xed 631-588-1300 1 c. lq~S Unemployment ~ce Employ~ ~e~afion Nmber of ~d 0592920-5 1 d. Fed=~ ~ployer Iden~on Nmb~ of ~d 1]-2245133 3a. Name of Imurance Carrier American International Co 3b. Policy Number of entity listed ~ box "la": WC1883215 3c. Policyaffectivape~od: 04/01/06 to 04/01/07 3d. The Proprietor, Partners or Executive Officers are: [~ lnclud~i (o.ly eboak box ff ~ ~ all excluded or ce~a~ par~ers/officers excluded. 3e. Demolition is: (Definition of Demolldon on Reverse) [~] thduded. ~] exdnded. ~ certifies that the insurance carder iadicated above ia box "3" k~su~es the bua~s refcrer~ed above ia box "1 a" for workzrs' compea~sation under ~e New York S~ate Workers' Compensation Law. Toe Irm~ranse Cosier or its licemsed agent will send ~ Certificate of Imuranee to the entity listed above as thc certificate holder ia box "2". The Inxurance Carrier will also notij~ the above certificate holder within 10 days ~ a policy is canceled due to nonpayment of premlums or within 30 days 1F there are reasons other than nonpayment of jTremiurns that cancel the'policy or eliminate the insured from the coverage i~ieated on ~ Cer~ficatt. (J'hese noffees may be sent by regUlar mail.) Otherwise, this Certificate is vail.d far a maximum of one year after thls form is approved by. the· i~su{rmce cat, tier or ~ts licet~sed agqnt. Please Note: Up on fl~e cancdlafi~m of the work,s' c~mp ensafion policy indicated on fids fonn, ff ~te business coxt~ues to be named on a permit, license or c~dract ~ by a certfficate holder, the business must provide that certificate holdex wiflx a new C~tificate of Workers' Co~p~msafi~m Coverage ot othex authorlzetl proof that rite bminess is con~pl.vlng wifl~ the mandatory coverage requ~remen*s of the New York State Workers' Compextsatlon Under penalty of perjury, I certify thai I am an authorized representative or licensed agent o f the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: Kevin McDonou ah (8igaatarc) (Dat~) Title: President of Walter Rose Agency, Inc Telephone Number of author/zed xepreseatative or licensed agent of insurance card~845) 783-2555 Please 2gote: Only insurance carriers and their licensed agen~ are authorized to issue the C-J)5.2 form. Jnsurance brokers are NOT authorized to issue it, C-105,2 (~ DATE (MMIDDtYYYY) ACORD. CERTIFICATE OF LIABILITY INSURANCE 03/ 0/06 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATIOt ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Walter Rose Agency, Inc HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 8 Stage Roac] ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW Monroe NY 10950 Phone: 845-783-2555 Fax: 845-783-2425 INSURERS AFFORDING COVERAGE NAIC # INSURERS: Twin City Fire Ins Co 347 Dunrite Manufacturi.ng Co.rp INSURERC: American International Co 3510 Veterans Memorial Hlghway INSURERD: Zurich Insurance Co. Bohemia NY 11716 COVERAGES 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 CONDmONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE SEEN REDUCED BY PArD CLAIMS. GENERAL LIABILITY EACH OCCURRENCE $ 1000000 A X COMMERCIALGENERAL LIABILITY 01UENQS9371 04/01/06 04/01/07 PREMISESJAMa~= IU~=l~lCU(Ea occurence} $ 300000 I CLAIMSMADE r~ occur MED~XP(Anyonepemen) $ 10000 X__ PO[:) U[3 PERSONAL&ADVINJURY $ 1000000 GENERAL AGGREGATE $ 2000000 GEN'LAGGREGATELIMITAPPLIESPER: PRODUCTS-COMP/OPAGG $ 2000000 --I POL,CY ~ O~CO~ [~ LOC Emp Ben. e_bar AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ i ~ 0 0 0 t 0 B ~ ANY AUTO 01UECGE8353 11/20/05 11/20/06 (Ea a~ident) EXCESS/UMBRELLA L]ABILITY i EACH OCCURRENCE $ IOCCUR [] CLAIMS MADE AGGREGATE $ WOR ERS OOMPENSATION ARD × I ORY"MITS I EMPLOYERS'LIABILITY WC1511544 04/01/06 04/01/07 E L. EACH ACCIDENT $ 100000 D NYS Disability 1737292 01/01/06 01/01/07 Statutor~ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SOUTH-7 Town of Southold Building Dept Main Street Southold NY 11971 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOtDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. ACORD 25 (2001/08) © ACORD CORPORATION I STATE OF NEW YORK WORKERS' COMPENSATION BOARD NOTICE OF COMPLIANCE DISABILITY BENEFITS LAW T~ ESTADO DE NUEVA YORK JUNTA DE COMPENSAClON OBRERA AVlSO DE CUMPLIMIENTO LEY DE BENEFICIOS PeR INCAPACIDAD 1. If you are unable to work because of an illness or injury not work-related, you may be entitled to receive weekly benefits from your employer, or his or her insurance company, or from the Special Fund for Disability Benefits. 2. To claim benefits you must file a claim form.within 30 days frQm the first date of vour disability, but in no event more than 26 weeks from such date. 3. Use one of the following claim forms: -If, when your disability begins, you are employed or are unemployed for four weeks or lees, use WHITE claim form (Form DB~,50), which you may obtain from your employer, his or her insurance carder, your health provider or any office of the Workers' Compensation Board, and send it to your employer or the insurance carder named below. -If, when your disability begins, you have been unemployed more than four weeks, use the GREEN claim form (Form DB-300), which you may obtain from any Unemployment Insurance Office, your health provider, or any office of the Workers' Compensation Board. Send completed claim form to the Workers' Compensation Board, Disability Benefits Bureau, Albany, New York 12241. IMPORTANT: Before filing your claim, your health provider must complete the "Health Care Provider's Statement" on the claim form, showing your period of disability. 4. You are entitled to be treated by any physician,chiropractor, dentist, nurse-midwife, podiatrist or psychologist of your choice. However, unlike workers' compensation, your medical bills will not be paid unless your employer and/or union provide for the payment of such bills under a Disability Benefits Plan or Agreement. 5. If you are ill or injured during the time you are receiving Unemployment Insurance Benefits, file a claim for Disability Benefits as soon as you sustain the injury or illness, by following the instructions outlined above. 6. If you are out of work in excess of seven days, your employer is required to send you a Disebitity Benefits Statement of Rights (Form DB-271). 7. Other information about Disability Benefits may be obtained by writing or calling the nearest Workers' Compensation Board Office. WORKERS' COMPENSATION BOARD OFFICES Albany. 12241 - 100 Broadway-Menands- (518) 474-6681 Binghamton. 13901 - State Office Bldg.-44 Hawley St.- (607) 721-8353 Buffalo. 14202 - Statler Towers - 107 Delaware Ave. - {716) 842-2166 Hauppauge, 11788 - 220 Rabro Drive - Suite 100 - (631) 952-6000 Hempsteed. 11550 - 175 Fulton Avenue - (516) 560-7745 New York City, 11248-0005 - 180 Livingston St.- Brooklyn - (718) 802-6964 Peekskill. 10566 - 41 North Division St. - (914) 788-5775 Rochester, 14614 - 130 Main SP'eet West - (716) 238~300 Syracuse, 13203 - 935 James St.- (315) 423-2934 1. Si usted no puede trabajar debido a enfermedad 0 lesion no relacionada con el trabajo, pedr(a tener dereeJ~ a recibir beneficios semenales de su patron o de la com~a~ia de seguros de 61/ella o der Fondo Especial para Benencios pot Incapacidad. 2. Para reclamar beneficies usted debe ereseetar una forma de reclamacion, dentro de 30 dias a Dartir de ia onmera techa de su inceDacidad, eero en ningun caso mas de 26 semanas de dicha fecha. 3. Use una de las siguientes formas de reclamaci0n: -Si cuando comience su incapacided usted sst~ empleedo o ha estado desempleado Pgr cuatro semanas 0 menos~ use la forma de reclamaciOn B[.ANCA (form DB-450), la cualpuede obtecer de su patron o de la compa~ia de s~guros de ~l/ella, o de su ,oroveedor de cuidados de salud o b~en de cualquier oficina oe la Junta de Compensaci0n Obrara, ~( enviela a su patron o a la compa~ia de seguros nombreda al)ajo. -S~ cuando comience su incapacided, usted ha estado desempleado m~s de cuatro semanas, use la forma de reclamaci0n VERDE(form DB-300), la cual puede obtener en cualquier Oficina de Seguro de Desempleo, de su proveedor de salud, 0 bien de cualquier oflctna de la Junta de Compensaci0n Obrera. Enwe la forma de reclamaci0n debidamente terminada, a Workers' Compensation Board, Disability Benefits Bureau, Albany, New York 12241. ~ Antes de presentat usted su reclamaci0n, es necesano qua su proveedor de salud compfie la declaracion del mOdico ("Heafih Care Provider's Statement") en la forma de relamacion, indicando el periodo de su incepacidad. 4. Usted tiene derecho a ser tratado per cualquier m~dice, quiropr~ctico dentista enfermera-partera podiatra o psicOiogo que usted eli. ia. Pare, centrario a la cempensaciOn obrera, sus cuentas medicas no seran pagadas a menos que su patron y/o Union haga el pa~.o de tales cuentas m~dicas bajo un Plan o Convenio de BeneT~cios per Incapacidad. 5. Si estuviers usted enfermo o lesionedo durante el tiempo que est~ recibiendo beneficios del Seguro de Oesempleo, presente uno reclamaci0n para Beeeficios por Incapac~dad, sig. uiendo las instrucciones arriba descritas, tan pronto como suTra la lesion o la enfermedad. 6. Si usted est~ desempleado per mas de siete dias, su patron est~ obligado a enviarle la Declaracibn de Derechos de Beneflcios per Incapacidad (Form DB-271). 7. Otras informaciones relativas a Beneficios per Incapacidad pueden obtenerse escribiendo o Ilamando a la oficina m~s cercana de la Junta de Compensacibn Obrera, Robert R. Seashell Chairman (Presidente) The undersigned employer is in compliance with the provisions of the Disabdity Benefits Law (El patron abajo firmante esta en conformidad con las disposiciones de la lay de Beneflcios per Incapaddad). Disability Benefits, when due, will be paid by (Los Beneflcios per Incapacidad, cuando debidos, seran pagados pot): Zudch American Insurance Company Disability Operations P.O. Box 9102 Plainview, NY 11803-9002 (800) 887~9111 (631) 845-2200 (Haste) THE WORKERS' COMPENSATION BOARD EMPLOYEES AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION The benefits p~ovided are (Los beneflcios provistos son) I X I Statutory I I I Under aP'an °r Agreement [ Class(es) of employees covered (Ciasa(s) de empleados ampamdos) ALL Name of employer (Nombre del Patron) DUNRITE MANUFACTURING CORP. pre$¢rll3~dbyChatr THIS NOTICE MUST BE POSTED CONSPICUOUSLY IN AND DB-120 (8-00) Wor~,.' C.,....~. ~ ABOUT THE EMPLOYER'S PLACE OR PLACES OF BUSINESS.