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HomeMy WebLinkAbout35207-Z TOWN OF SOUTHOLD BUILDINGDEPARTMENT TOWN CLERK'S OFFICE oy . 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#: 35207 Date: 12/10/2009 Permission is hereby granted to: Ovsianik, Allen 618 Ridge Ave Ephrata, PA 17522 To: REMOVAL OF FUEL TANKS AS APPLIED FOR At premises located at: 32930 Route 25 SCTM # 473889 Sec/Block/Lot# 97.-2-15.1 Pursuant to application dated 12/7/2009 and approved by the Building Inspector. To expire on 6/10/2011. Fees: FENCES/WD STV/SATT/TENNIS CT $250.00 Total: $250.00 Building Inspector I TOWN OF SOUTHOLD BUILDING PERMIT APPLICATION CHECKLIST BUILDING DEPARTMENT Do you have or need the following,before applying? TOWN HALL Board of Health SOUTHOLD,NY 11971 4 sets of Building Plans = TEL: (631) 765-1802 Planning Board approval FAX: (631) 765-9502 _ Survey SoutholdTown.NorthFork.net PERMIT NO. J d67 � Check Septic Form N.Y.S.D.E.C. Trustees Flood Permit Examined /la ,20 Storm-Water Assessment Form c Contact: Approved ��� ,20 / Mail to:,6A Disapproved a/c 7�/�.�u�'�r1/,9n/, 'c• ��nx�erJl�[E✓S7k'/y� Phone,/L 5,23-V7,T6 Expiration eq ,20/l/ ® E LW E Building Inspector �® 2 200 APPLICATION FOR BUILDING PERMIT Date // /9 52007 DG.DE . INSTRUCTIONS TOWN OF SOUTHOLD 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 after 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, Suffolk County,New York, and other applicable Laws, Ordinances or Re lat' ,;,fir tl yt ildings, additions, or alterations or for removal or demolition as herein described.The a t r t c+ v h1 blicable laws, ordinances,building code,housing code, and regulations, and to admit as a 'in building for necessary inspections. DEC 7 2009 �.� a- L.' �i o (Signature of applicant or name,if a corporation) BLDG.DEPT. TOWN OF SOUTHOLD 7/p�'A11mA,0 AI)c', Lii9d,-A)�trs7-/V. (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor; electrician, plumber or builder ° A I`P t`111-1 i'�.P AS, I'd09 Name of owner of premises /few 4)° °,F _ % 3 r7 (As on the tax roll or 1 es­ deed) If applicant is a corporation, signature of duly authorized officer FF`E'� �' - - - F t': ,FWWAa eb,- Pc-s;tear/ N07iF4" B �Ci s,;MIEENT AT Name and title of corporate officer 765-1802 B , .; +' FOR THE F01 LO',TNIGS Builders License No. F(311­; ;OUR"C; Plumbers License No. -'O 8 13 7 2. ROUGH - H_UIv!SING Electricians License No. 3. INSULAT!0N Other Trade's License No.Nhsso i o4.vly r-,e149-1/,s/ ;WWW i '0191/l 'NAL ` CO!`51 r,UCT!ON MUST BE COMPLE i E FC C.O. 1. Location of land on which proposed w rk will be done: ALL CONSTRUCTION SHALL MEET THER ENTS OF THE CODES OF NEW :3�z 1,730PSf 02's- li.#;k Aer OF we- If_)_QTATE. NOT RESPONSIBLE!BLE FOR House Number Street �-7 DES!G RileONSTRUCTION ERRORS. County Tax Map No. 1000 Section Block Lot Subdivision 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 ee-t ,l e Sdes b. Intended use and occupancy JCe hl-�- S/,o 3. Nature of work (check which applicable): New Building Addition Alteration Repair Removal ,/ Demolition Ll-*- Other Work (Description) 4. Estimated Cost '�'�� �- Fee (To be paid on filing this application) 5. If dwelling, number of dwelling units Number of dwelling units on each floor If garage, number of cars 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use. Gsdlt�e Stato,v 7. Dimensions of existing structures, if any: Front Rear Depth Height Number of Stories Dimensions of same structure with alterations or additions: Front Depth Height Number of Stones` .....d i j I..t 6 8., Dimensions of entire new construction: Front Rear Vepth Height Number of Stories 9. Size of lot: Front Rear Depth 10. Date of Purchase Naive of Former Owner 11. Zone or use district in which premises are situated leusl+ess 12. Does proposed construction violate any zoning law, ordinance or regulation? YES NO_Z 13. Will lot be re-graded? YES NO /Will excess fill be removed from premises? YES NO t/ 14. Names of Owner of premises 411coiJ- 0iS14,y k Address� &e . Phone No. 611' 74-5- 12V97- Name of Architect Address Phone No Name of Contractor s Cd Address 7G r.llfl1mea Avg_Phone No.0 7- L��cfe��iu�s7' 75-7 51b 15 a. Is this property within 100 feet of a tidal wetland or a freshwater wetland? *YES;;:- ",`:NVQ.`--, '; ;-- * IF YES, SOUTHOLD TOWN TRUSTEES & D.E.C. PERMITS MAYBE REQ� D.�IRE1'"1 ,J ' I 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 propert lineL­-._r .-._m-•�T`a„� 17. If elevation at any point on property is at 10 feet or below, must provide topogr phiEalata on•suruey� ,�.,.,q, 18. Are there any covenants and restrictions with respect to this property?.* YES NO * IF YES, PROVIDE A COPY. STATE OF NEW YORK) SS: COUNTY OF ) I�Vlae / � being duly sworn deposes and says that (s)he is the applicant (Name of individual signing contract) above named, (S)He is the ( ontracto , 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 state ' nts contained in thisation are tine to the best of his knowledge and belief, and that the work will be performed in he manner set forty in the pplication filed therewith Sworn to b fire me this �. Ilday of s.1 Ov 0 _ Not Pub- FB A D C _- tate o-►v.�9 Yo,4 t, otary Publ alifia 'M-_-W-” Signature of Applicant Comm ro�Coanty sioee Exair®s vcI-S' l b z� � Town -.of Southold Erosion, Sedimentation & Storm-Water Run-off ASSESSMENTPORM l [COO LOCATION: S.C.T.M. THE FOLLOWING'ACTIONS MAY REQUiRE THE SUBMISSION OFA L�G L STOlIiXl�IiATER,G UINGy DRAIN GE AND EROSION CONTROL PLAN District St ctipn Block . Lot CERTIFIED BY�1 DESIGN PROFESSIONA IN THE STATE OF NEW - YORK. —� ------- -------------------*---=-------- ______ Item__ Number. (NOTE: A Check Marc(4)for each Question is Required for a Complete Application) — _----- Yes No ———— -------- ------------ ___ ___ __ Will this Project Retain All Stonr>~Water Run-Off Generated by a Two(2")Inch Rainfall on Site? — — (This'item will,indude all run-off created by site Clearing and/or construction activities as welt as alt Site Improvements and the permanent creation of impervious surfaces.) 2 Does the Site Plan and/or Survey Show All Proposed Dfainage Structures Indicating Size&Lobation? This Item shall include all Proposed Grade Changes and Slopes Controlling Surface WaterFlowl — 3 Will this Project-Require any Land•Fiiling,Grading or Excavation where there is a change to the Natural Existing Grade Involving more than 20a Cubic Yards of Material within any Parcel? _ 4 Will this Application Require Land Disturbing Activities Encompassing an Area in Excess of V/ Five Thousand(5,000)Squaw Feet of Ground Surface? _ 5 Is there a Natural Water Course Running through.the Site? Is this Project.w)thin the Trustees jurisdiction or within One Hundred(100')feet of a Wetland or Beach? El Will there be Site preparation on Existing Grade Slopes which Exceed Fifteen(15)feet of Vertical Rise to One Hundred(100')of Horizontal Distance? 0 —/ 7 tNll Driveways,Parking Areas or other Impervious Surfaces be Sloped to Direct Stohn-Water Run-Off into and/or in the direction of a Town dght-:of--way? $ Will this Project Require the Placeirient of Material,Removal of Vegetation and/or:the Construction of El ` any Item Within the Town Right-of-Way-or Road Shoulder Area? _ (This item will,NOT include the Installation of Driveway Aprons.) + 9 Will this Project Require Site Preparation within the One,Hundred(100)'Year Floodplain of any Watercourse? NOTE: If Any Answer to Questions One through Nine is Answered with a Check Mark in the Bdx, a Stbrm-Watery Grading, —— Drainagej&Erosion Control Plan Is Required and Must be Submitted for.Review Prior to Issuance of Any Building Permit! EXEMPTION' ----------------------- ' Yes Na Does this project meet the minimum standards for dassifica"ri as an Agricultural Project? Note: if You Answered Yes to this Question,it Storm-Water,Grading,Drainage&Erosion Control Plan Is NOT Requiredl• STATE OF NEW YORK, _-- '—" —_----- - --------LL-----------.----— COUNTYOF..........................................SS That r,��A�� t'_"l... �� ............... /..' k k..... ... ..............................being duly sworn,deposes and says that he/she is the'app icantfor Permit, (Name of Individual signing Documen) Andthat he/she is the C.I 4A rc!: '.� .. ......................... ... ................................... .............................. (Owner,Contractor,Agent,Corporate Officer,etc.) Owner and/or representative of the Owner Of Owner's,and is duly authorized to perform or have performed the said work and to make and hie this application;that all statements contained in this application are true to the best of his knowledge and belief,and that the wor k will be pe an ved in the m t forth in the application filed'herewith. Sworn to before me thi .............. .................�. .......day.of: ,:.. ............ 200.0� , ., GEBF)ARD Notar� to c SPaf dvd York 1�iotary Pub .... � .Gdj.. ........ .. .... . o,.� .......................... 1 S ... .............. Q alified in Suffolk Gounly- t +9nature-of Applican() FORM'- 06107 ommr stun EGros OGr%ti'w Is Telephone (631) 475-1450 E-mail: gmdege@optonline.net Facsimile (631) 475,-1238 www.gmdege.com G or- N DJEGE, Inc. Est. 1961 • SERVICE • MAINTENANCE • INSTALLATION Service Station Construction • Tank Removals & Installation Pumps & Dispensers • Electronic Tank Monitoring System Tank Testing • Signs & Lighting • Lift Installation 250 ORCHARD ROAD, EAST PATCHOGUE, NEW YORK 11772 March 1,2009 To Our Valued Customer, G&M Dege,Inc,is a full service pump and tank contractor, Our hours of operation are Monday thru Friday-7:30 A.M.-4:30 P.M. In the event of an emergency,after hours services are available. G&M Dege,Inc.provides the following services: INSTALLATION AND MAINTENANCE OF GASOLINE/DIESEL PUMPS INSTALLATION AND MAINTENANCE OF ELECTRONIC ALARM MONITORING SYSTEMS ON TANKS CERTIFIED TANK AND LINE TESTING TANK INSTALLATIONS AND REMOVALS 1 INSTALLATION AND MAINTENANCE OF AUTOMOTIVE/TRUCK LIFTS INSTALLATION AND MAINTENANCE OF AREA LIGHTING AND SIGNS Please do not hesitate to call with any questions and we look forward to having the opportunity to provide our services to you in the near future. Sincerely, �'�/J ,- � ��J� � � � , ��6v ® ECE � � � NancyP Galli oli-Barrie -- G&M Dege,Inc. DEC 1 1 2009 BLDG.DEPT. TOWN OF On,"'.OLD _ STATE OF NEW YORK `WORKERS'COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATIO�'V INSURANCE -COVERAGE " la.Legal Name& Address of Insured(Use street address only) 1b.Business Telephone Number ofIns ured, BUSINESS-,RESEARCH CONSULT ANTS,,Lr1' 681-587-0916 'EDWARD L. CLARK•;DBA ELCO/BRC ­` - 7 6 EAST 'HnFFMAN' A�7ENTTF lc.NYS Unemployment Insurance Employer LTNDENHTTR$'T' NY 11257 Registration Number of Insured ' Work Location of(nsured(Onlyrequired ifeoverage,isspecifkally Id.Federal Employee Identification Number of Insured limited ro certain locations,in-New York State, i.e., a 'Wrap.Up or Socia Policy) al'Security Number _ 1131983'9-7= 2.Name and Address of the Entity Requesting_Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) ' GUARDIAN ,LIFE INSURANCE „ 3b.Policy.N umber of entity listed in box"la" TOWN OF SOUTHOLD-:'- : 980119-001 BTTTLDI�NG DEPT' " . = „mpraN; HALL 3c. Policy effective period ., SOTTTHOLD - NY'"119 7 -: 0-6/02/2009' to 06/0212010 _ 3d. The Proprietor,Partners or Executive-Officers are- - included (Only cbeck box if xdl partners/offices induded)' - - .- all excluded or certain-partners/officers'eacluded.- This certifies'that the insurance carrier indicated above in box "3" insures the business referenced above.in box "la" for workers' compensation undertheNew York'tateWorkers,CompensationLaw (To use this form,New York(NY)must belisted underItem 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 Tke Asuraxce Carrier will also norify,rhe above cerri�fcai a holder,ivi(kin 10 days IFa policyis canceled due(o nonpaymen(ofpremiums or _ . within 30 days iFrhere#'rereasonsotherthanxonpaymemeofpremumithatcancelthepolicyoreliminaterheitsuredfororhecoverage - ,indicaredox(fiisCertificate.-(Thesenoticesmaybe.-c.m by regular mail.) Orkerwise,rkisCerrifrcareisvalidforoue)tarafterthisfarm is approved hytke insurance carrier or its Acexsed asexr;or,urstil rhe policy expirarios'dare[Erred is box"3c";w*ickever is earlier. Please Note: Upon ihe'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 ,Certificate of Workers' Compensation Coverage or other, thorized proof that th'e business is complying with the mandatory ' coverage requirements of the New York-State Workers'Compensation Law. Under penalty of perjury,I certify that I am an authorized representative or licensed agent of'the insurance carrier referenced s %above and_that the named insured has the coverage,as depicted on this form. , Approved by_ = TAKACTI ,-&.' ASSOCIATES, INC.. (PtiuhtHtmeofnutho z%rq_Vreenf:zttt 0rlicenzeda0entofin3urancecamer) ` Approved by: - 03te) Title.i•' PRESIDENT - -Telephone Number of authorized rep-esentative or licensed agent of insurance carrier. 631-366-2774 Please Note: Only insurance,carriers and(f eir licensed agents are authorized to issue C-105.2.'htsurance brokers are NOT, kurhorized(o'rssue i(. ' ,C-105.2 (9-0T) - _ www.wcl .swe'.ny us STATE OF NEW YORK WORKERS'COMPENSATIONBOARD CERTIFICATE OF INSURANCE COVERAGE UNDER THE NYS DISABILITY BENEFITS LAW [ PART 1. To be-completed by Disability Benefits Carrier or Licensed Insurance Agent of that Carrier [a- Legal Name and'Address of Insured(Use street address only) lb.Business Telephone,Number of Insured BUSTNESS RESEARCH CONSULTANTS,L D 631-5'87=0916 EDWARD L -CLARK,DBA ELCO/BRC Ic_NYS Unemployment Insurance Employer Registration , 76 EAST' HOFF'MAN AVENUE Number of Insured LTNDENHTTRS'T' NY 11757 - F Id.Federal Employer Identification Number of Insured or Social Security Number 113198397 '. Name and Address of the Entity Requesting Proof of 3a. ;Mame of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder), HARTFORD PERSONAL -INSURANCE , , 3b.Policy Number of entity listed in box"1 a',- . . TOWN OF SOUTHOLD 12WECHO3815 $TTTLD_TNG DEPT' 3c. Policy effective period- E TOWN HALL SOTTMHnLD NY 11971 03/0312009 to 03/03/2010 - 4.Policy covers: f I a-® All of the employer's employees eligible under the New York Disability Benefits Law ! ` b.❑ Only the following class or classes of the employer's employees: Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured'has NYS Disability Benefits insurance coverage as desct�dbesabove. Date Signed 11120- 1200� By (S tgnature of insurance tamer's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) ( Te{ephone Number• '01-366-2774 -Title - _• PRESIDENT j'(:YIPORTANT If box"4a"ns checked,and this form is signed by the insurance earner's autttonzed representative or NYS Licensed Insurance Agent of rh:tr j _ carrier,-this certificate is COh1PLETF- MA it directly to the certificate holder. If box"ib"is checked,this certificate is NOT COMPLETE for purposet,ofSection 220,Subd.S of the Disability Benefits Law It must be mailed i for completion to the Workers'Compensation Board,DB Plans Acceptance Unit.20 Park Street.Albany,New York 12207. PART 2. To be completed-by NYS Workers' Compensation Board(Only if box"4b"of Part 1 has been checked)';.- State hecked)';State Of New York Workers' Compensation Board = ' i According to information maintained by the NYS Workers'Compensation Board,the above-named emplover has complied with the,N Y S ! Disability Benefits Law with respect to all of his/her employees Date Signed' By i _ - (Signature of NYS Workers'.Compensahon Board Employee) - I Telephone Number, Title Please,Vote:Only insurance carriers licensed to write NYS disability benefits insurance policies and NYS licensed insurance agents of those insurance carriers`are authorized to issue Form DB-170 L Insurance brokers are NOT authorized to issue this form DB--120.1 (5-06) Additional Instructions for Form}.DB-120.1 ; By signing this form,the insurance carrier identified in bbx"T"on this form is certifying that it is insuring the business referenced in box "la"foTdisability benefits under the New York State Disability Benefits Law.The Insurance Carrier or its licensed agent will send this w, Certificate of Insurance to the entity,listed as the certificate holder in box"2". This Certificate is valid for the earlier ofane year after rhis ' form is approved by the insurance-carrier or its licensed agent,or the policy eepiration daze listed in box"3c"., Please Note:upon the cancellation of the disability 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 NYS DisabilityBenefits-Coverage�or. other authorized proof that the business is complying with the mandatory coverage requirements of the New_York State Disability Benefits Law =- ' DISABILITY BENEFITS LAW §220."Subd. 8 (a),The,head of"a'state or muni cipal: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 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 notwithstariding,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 for all employees has been secured as provided by this article. DB-120.1(5=06)Reverse - ; 1 ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE 009Y' PRODUCER (631)581-8400 FAX: (631)581-4700 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Mal i li and Salva io Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P g gg g cY HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 3311 Sunrise Highway ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Islip Terrace NY 11752 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA Star Indemnit G & M Dege Inc. INSURER Tower Insurance Co 250-Orchard Road INSURER C Mt Hawley Ins Co INSURER D East Patchogue NY 11772 INSURER E OVERAGES 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 AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR INSRD NSR ADD'L POLICIRATION TYPE OF INSURANCE POLICY NUMBER DATEYMM DD/YYEFFECTIVE POLICY MPDDNY) LIMITS A GENE RALLIABILITY SISIEIL70023709 12/04/2009 12/04/2010 EACH OCCURRENCE $ 6,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGPREM SES Ea occurrence)RENTED $ 50,000 CLAIMS MADE FX]OCCUR MED EXP(Any oneperson) $ 5,000 X Contractual Liabili PERSONAL&ADV INJURY $ 6,000,000 X XCU GENERAL AGGREGATE $ 6,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $ 6,000,000 PRO- POLICY 0 JECT LOC B AUTOMOBILE LIABILITY BAP2610423 12/04/2009 12/04/2010. COMBINED SINGLE LIMIT ANY.AUTO (Ea accident) $ 1,000,000 ALL OWNED AUTOS BODILY INJURY (Per person) $ l X SCHEDULED AUTOS X HIRED AUTOS BODILY INJURY X -NON,OWNEDAUTOS-., - - - -- - _ (Per accident) $ PROPERTY DAMAGE $ (Per accident)' GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY AGG $ C EXCESS/UMBRELLA LIABILITY bOM0413806 EACH OCCURRENCE $ 2,000,000 X OCCUR F1 CLAIMS MADE Excess Auto Liab3.lity 12/04/2009 12/04/2010 AGGREGATE $ 2,000,000 $ DEDUCTIBLE $ RETENTION $10,000 $ WORKERS COMPENSATION AND WC STATU- OTH- EMPLOYERS'LIABILITY ER ANY PROPRIETOR/PARTNER/EXECUTIVE EL EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED EL DISEASE-EA EMPLOYEE$ If yes,describe under SPECIAL PROVISIONS below EL DISEASE-POLICY LIMIT $ A OTHER Pollution Coverage SISIEIL70023709 12/04/2009 12/04/2010 Lm=t 6,000,000 Ded 10,000 DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS - Job Locatin: Hess Station # 32481, 11100 Route 25 & Bay Ave Mattituck, ;NY - - -- - CERTIFICATE`HOLDER CANCELLATION SHOULD,ANY OF THE ABOVE DESCRIBED`POLICIES BE CANCELLED BEFORE THE Town of Southold EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL 'ENDEAVOR TO MAIL Building Dept. 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT Main Road FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE Southold, NY 11971 INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Anthony Salvaggio/DP rte* - "�v~�`T } ACORD 25(2001/08) ©ACORD CORPORATION 1988 INS025(0108)08a Page 1 of 2 ACORDM CERTIFICATE OF LIABILITY INSURANCEDATE(MM/DD/YYYY) 11/2012009 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Takach&Associates,Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 112 Terry Road ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Smithtown NY 11787 INSURERS AFFORDING COVERAGE NAIC# INSURED BUSINESS RESEARCH CONSULTANTS LTD INSURER MARKEL EDWARD L CLARK,dba ELCOIBRC INSURER B. HARTFORD PERSONAL INSURANCE 76 EAST HOFFMAN AVENUE INSURER C GUARDIAN LINDENHURST NY 11757 INSURER D INSURER E 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 CONDITIONS OF SUCH POLICIES AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD' TYPE OF INSURANCE POLICY POLICY NUMBER EFFECTIVE POLICY EXPIRATION LIMITS LTR NRRGENERAL LIABILITY EACH OCCURRENCE $1,000,000 A X COMMERCIAL GENERAL LIABILITY 09PKGM00117 0412512009 0412512010 DAMAGE TO RENTED $50,000 CLAIMS MADE 7 OCCUR MED EXP An one person) $5,000 PERSONAL&ADV INJURY $1,000 000 " GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $2,000,000 17 POLICY M PRO LOC AUTOMOBILE LIABILITY " COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS _ BODILY INJURY 'NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR F—I CLAIMSMADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND WC STATU- O R B` 'EMPLOYERS'LIABILITY 12WECH03815 0310312009 03103/2010 E L EACH ACCIDENT $100,000 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? EL DISEASE-EA EMPLOYEE $100,000 If yes,describe under SPECIAL PROVISIONS below EL DISEASE-POLICY LIMIT $SOO,000 OTHER C NY STATE DISABILITY 980119-001 0610212009 0610212010 STATE LIMITS DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS TOWN OF SOUTHOLD IS LISTED AS ADDT'L INSURED. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION TOWN OF-SOUTHOLD DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 15 DAYS WRITTEN BUILDING DEPT NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL TOWN HALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR SOUTHOLD,NY 11971 REPRESENTATIVES. AUTHORIZED REPRESENTATIVE <JAB> ACORD 25(2001108) ©ACORD CORPORATION 1988 t�' ..� - t• ._.._...r.r- •'� I •t .• ,.� mss, � � ' A 41 , J / O `' '` ,•c ,` ,.;1 KKK �y,; T}//, �; '� r'✓' r,i SIV• ` � ' � >t F�c.r E/. +'' • � "V -� •`r �•r � ..- ,yam '� ., •, �. Lly .3 E! 1 ,} En/2.4 f/�/2.9 ��� E/},/�•G •,1 �'yi/J.L / •.