HomeMy WebLinkAboutI - 10 Cortland Estates Mobile Home Park Permit Renewal ApplicationJ.
TOWN OF CORTLANDVILLF , NOV 23 2022
RAYMOND G. THORPE MUNICIPAL BUII,pING
3577 TERRACE ROAD f
CORTLAND, NEW YORK 13045" #
PHONE: 607-756-5725 FAX: 607-756-4659
WEBSITE: WWW.CORTLANDVILLE.ORG
NO.
RENEWAL APPLICATION FOR MOBILE HOME PARK PERMIT
TO: The Town Clerk of the Town of Cortlandville, Cortland County, NY
CNY MHPS. LI,C _ of 90 Ai%ark Dr. 4400. Rochester- NY 14624
(Name of Operator) (Address of Operator)
Hereby makes application for permission to establish, construct or maintain a Mobile Home Park for the
year M ol!) .
Park Location: 1054 Route 13 Tax Map #: 96.09-04-10.000
Name of Park: Cortland Estates Mobile Home Park
Such premises are owned by:
Gltf 0N15,LL of'10 AIFPArlk �r .�`�OO� %�av�rPS''rc /0/ i�6ay
(Name of Owner) (Address of Owner)
Phone#: g�`I rfl�aa Email:A1-y"+M1,1v Coo (-,r-i-
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Partner's name if partnership exists: / y U
On -Site Park Manager: /� �Cm !E ll , y l Phone #: r- s� N ✓ 9 / °?
The proposed/existing park will provide Park Units for the. location of
Annual Fee: $5.00 per Park Unit Total Amount Due: $ F ��
(Note: The Minimum fee charged is $25.00 per year)
Filed herewith is a complete plan to scale showing the layout of the mobile home park, the
location, size and areas of each mobile home unit, the locatloDQf streets, and fire hydrants.
/j
Dated: / I I I 'T , 20 as Yr /
(Applicant)
For Office Use:
Amount Received $ Cash Check #
Date Paid: Received By:
(912ota)
4sTNIW Workers' Certificate of Attestation of Exemption
ATI: Compensation from New York State Workers' Compensation and/or
Board Disability and Paid Family Leave Benefits Insurance Coverage
"This form cannot be used to waive the workers' compensation rights or obligations of'attyparty."
The applicant may use this Certificate of Attestation of Exemption ONLY to show a government entity that New York State
specific workers' compensation and/or disability and paid family leave benefits insurance is not required. The applicant
may NOT use this form to show another business or that business's insurance carrier that such insurance is not required.
Please provide this form to the government entity from which you are requesting a permit, license or contract. This Certificate will
not be accepted by government officials one year after the date printed on the form.
In the Application of
(Legal Entity Name and Address):
CNY MHPS, LLC
90 Airpark Dr Ste 400
Raebester, NY 14624.5732
PHONE: 585-721-0602 FEIN: XXXXX5085
Workers' Compensation Exemotion Statement:
Business Applying For:
Mobile Home Park Permit
From: Town of Cortlandville
The above named business is certifying that it is NOT REQUIRED TO OBTAIN NEW YORK STATE SPECIFIC
WORKERS' COMPENSATION INSURANCE COVERAGE for the following reason:
The business is a LLC, LLP, PLLP or a RLLP; OR is a partnership under the laws of New York State and is not a corporation. Other
than the partners or members, there are no employees, day labor, leased employees, borrowed employees, part-time employees, unpaid
volunteers (including family members) or subcontractors.
Partners / Members: Brian Cook, Jeff Cook
Disability and Paid Familv Leave Benefits Exemotion Statement:
The above named business is certifying that it is NOT REQUIRED TO OBTAIN NEW YORK STATE STATUTORY
DISABILITY AND PAID FAMILY LEAVE BENEFITS INSURANCE COVERAGE for the following reason:
The business MUST be either: 1) owned by one individual; OR 2) is a partnership (including LLC, LLP, PLLP, RLLP, or LP) under
the laws of New York State and is not a corporation; OR 3) is a one or two person owned corporation, with those individuals owning
all of the stock and holding all offices of the corporation (in a two person owned corporation each individual must be an officer and own
at least one share of stock); OR 4) is a business with no NYS location. In addition, the business does not require disability and paid
family leave benefits coverage at this time since it has not employed one or more individuals on at least 30 days in any calendar year in
New York State. (Independent contractors are not considered to be employees under the Disability and Paid Family Leave Benefits Law)
I, Brian Cook, am the Member with the above -named legal entity. I affimr that due to my position with the above -named business I have the knowledge,
information and authority to make this Certificate of Attestation of Exemption. I hereby affirm that the statements made herein are true, that I have not
made any materially false statements and I make this Certificate of Attestation of Exemption under the penalties of perjury. I further affirm that I
understand that any false statement, representation or concealment will subject me to felony criminal prosecution, including jail and civil liability in
accordance with the Workers' Compensation Law and all other New York State laws. By submitting this Certificate of Attestation of Exemption to the
government entity listed above I also hereby affirm that if circumstances change so that workers' compensation insurance and/or disability and paid
family leave benefits coverage is required, the above -named legal entity will immediately acquire appropriate New York State specific workers'
compensation insurance and/or disability and paid family leave benefits coverage and also immediately furnish proof of that coverage on forms approved
by the Chair of the Workers' Compensation Board to the government entity listed above.
SIGN HERE I Signature: 57Exemption Cer ' icate Number
2022-077602
Date: 1111.7 � � d
Received
November 17, 2022
NYS Workers' Compensation Board
CE-200 01/2018
Al
Cortland Estates
1054 NYS-13
Cortland, NY 13045
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4 Uodmark Dr.
4 Penguin Park owned?
6 Penguin Park
33 Penguin
43 Penguln
47 Penguin or 247 Penguin?
56 Penguin
159 Penguin
178 Penguin