HomeMy WebLinkAboutI - 15 Mobile Home Park Renewal Permit CNHTOWN OF CORTLANDVILLE 1 5 l??
RAYMOND G. THORPE MUNICIPAL BUILDING
3577 TERRACE ROAD
=.... CORTLAND, NEW YORK 13045
PHONE:607-756-5725 FAX: 607-756-4659
WEBSITE: WWW.CORTLANDVILLE.ORG
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RENEWAL APPLICATION FOR MOBILE HOME PARK PERMIT
TO: The Town Clerk of the Town of Cortlandville, Cortland County, NY / I f
l �''� tC�Y AK& of o?a .1%�rA7 Xuy*)�y N"/ 1Z2US�
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(Name of Operator) (Address of Operator
Hereby makes application for permission to establish, construct or maintain a Mobile Home Park for the
year 20Z23_.
Park Location: 3610 Kinalsev Ave.
Name of Park: CNH Trailer Park
Such premises are owned by:
SkEF � r'4, A-0,
(Name of Owner)
Phone #:
Tax Map #: 96.09-04-14.000
of a'q' Ad&K A y Z 0 o
(Address of Owner)
Email: sko—A- P�� (2- �Ywilb ,
Partner's name if partnership exists:� / �7
On -Site Park Manager: /all , `l0o t 414 Phone
The proposed/existing park will provide Park Units for the location of l mobile homes.
Annual Pee: $5.00 per Park Unit Total Amount Due: $
(Note: The Minimum fee charged is $25.00 per year)
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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 location of streets, a re h - nts.
Dated: 20 i _
(Applicant)
For Office Use:
Amount Received $ Cash Check #
Date Paid: Received By:
(9/2018)
E::�N'W Workere Certificate of Attestation of Exemption
YORK
STATE Compensation • _ •rk State • _' Compensation an• •
Board Disability 1 PaidLeave Family BenefitsCoverage
"This form cannot be used to waive the workers' compensation rights or obligations of any party."
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):
Bret Peek
22 Kraft Ave
Albany, NY 12205-5420
PHONE: 518-365-0817 FEIN: XXXXX5651
Workers' Compensation Exemption Statement:
Business Applying For:
Health Permit or License
From: NYS Dept of Health
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 owned by one individual and is not a corporation. Other than the owner, there are no employees, day labor, leased
employees, borrowed employees, part-time employees, unpaid volunteers (including family members) or subcontractors.
Disability and Paid Family Leave Benefits Exemption 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, Bret Peek, am the Sole Proprietor with the above -named legal entity. I affirm 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 Si nature:
HERE g
Exemption Certificate Number
2022-082387
Date:
December 12, 2022
NYS Workers' Compensation Board
CE-200 01 /2018
GNH
Town of Cortlandville
Building and Codes Department
3 577 Terrace Rd
Cortland, NY 13045
Desiree Campbell
NYS Code Enforcement Officer
Town of Cortlandville
MEMORANDUM
November 15, 2022
Dear Board Members,
Phone: 607-756-7490
Fax: 607-758-7922
On October 14, 2022, I completed an exterior property maintenance inspection of
the CNH Mobile Home Park, also known as Kingsley Ave Mobile Home Park.
Inspection revealed the park to be in good condition. I noted a fear items that
needed attention which are in the process of being handled with the park manager.
I would recommend the Board grant the renewal of application permit, pursuant to
the Local Town Law, Section 151-10.
If you should have any questions, please feel free to contact me.
hank you,
can Lt(-,
esiree Campbell
NYS Code Officer
Town of Cortlandville
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i; N 0V 1 6 2022