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HomeMy WebLinkAbout096.09-04-10.000 15/2023�5�aba3d Q �\O4 Y z! r r TOWN OF CORTLANDVILLE 3577 Terrace Road, Cortland NY 13045 607-756-7490 4�g. BUILDING PERMIT APPLICATION _ Fee Paid:64Permit No, M- 6 Application Date: Name of Property Owner. (fAJY RPA5, ZZ , Mailing Address& Email Address: e) o: Tax Map No. Phone #: S L+e V09 J&G 4v,SAer t P( 11 5/ Application its Hereby Made to (construct, add, modify, etc.) ewo✓e e� l /h&1.-� Zj rPit�u� t [fir at(address) t1/pet<cr,..� i�r �or(!e+-.�Y l Y / 1 Number of Family Units 1 Basement? /VL9 Area (SF) First Floor Area (SF) 7 �L. 70' Second Floor Area (SF) Total Area above Second Floor (SF) Size of Building i Y / or Size of Lot 711 /( tb6; Setbacks: Front 3 Rear �% /,r Left Side Right Side S Sewage Disposal 1070K G pot- Water Supply wro K c �dc Type of Heat tV Date of Health Department Approval Builder's Name: Estimated Cost: Phone Number: �'a'S� ,�O 3' 7vr0�i, OCC Class: Submit drawings showing the location of the building on the lot in relation to the property lines. A set of Building Plans detailing: the foundation, framing, grade and species of lumber, Energy Code Compliance, sheathing, interior walls, stairs, windows and other information that may be necessary to determine compliance with the N.Y.S. Building Codes. All Statements contained herein are true and the work will be performed in the manner set forth in this application in accordance with all codes of the State of New York and all laws, ordinances, codes and regulations of the Town of Cortlandville, New York. Certificate of Occupancy is required upon occupying the premises. The undersigned grants the Town Building Inspector permission to enter upon the premises at all reasonable times for the purpose of making necessary inspections. Inspections require 24- hour notice by th�j�,pplicant. pp _ Per itA ed Signatuw4f/Applicant Permit Date: Nb" &-W VD . Si ture of Inspector 'k r L - "- \/R Cam) Signature of Cortlandville Town Clerk Building Permit # D23-15 TOWN OF CORTLANDVILLE 3577 Terrace Road Cortland, NY 13045 607-756-7490 Date Issued:11/21/2023 This notice, which must be prominently displayed on the property or premises to which it pertains, indicates that a BUILDING PERMIT Has been issued to: CNY MHPS LLC Permitting: CNY Cortland Estates demo Dermit for removal of abandoned home at 41 Penauin Drive At: 1054 Route 13 All work shall be executed in strict compliance with the permit application, approved plans, the NYS Uniform Fire Prevention and Building Code, and all other laws, rules and regulations, which apply. The building permit does not constitute authority to build in violation of any federal, state or local law or other rule or regulation. SDecial Notes (if anv) : Do not proceed beyond these points until countersigned below by the inspector. Footing before pouring concrete Framing before closino Plumbing before enclosina Insulation inspection Footing before backfill Electrical before enclosing_(BY OTHERS) HVAC before enclosing Final lnspection X Permission is hereby granted to proceed with the work as set forth in the specifications, plans, or statements now on file in this department. Any amendments made to the original plans or specifications must be submitted for approval. Permit Expires: 11/21/2024 `� Issuing Officer: Desiree Campbell/ Kevin McMahon TOWN OF CORTLANDVILLE o ,t �aFW yo�� 607-756-7490 CERTIFICATE OF COMPLIANCE Having complied with the provisions of the Local Laws of the Town of Cortlandville and the NYS Fire Prevention and Building Codes as per application type: Demolition, The below named permit holder is hereby granted this Certificate of Compliance. CNY MHPS LLC 90 Airpark Drive Rochester, NY 14624 96.09-04-10.000 Building Permit # D23-15 Type of Permit: Demolition Issued on: 11/21/2023 Completed on: 12/19/2023 Description of work: CNY Cortland Estates demo permit for removal of abandoned home at 41 Penguin Drive i l By Order of NYS Code Enforcement Officers: Desiree Campbell & Kevin McMahon //"-1\ NYSIF New York state Insurance Fund PO Box 66699, Albany, NY 12206 ( nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE N A A A A A 522414777 DURNAN GROUP INC PO BOX 390 ROCKVILLE CENTRE NY 11571 POLICYHOLDER HIGHLAND HOLDINGS LLC 90 AIRPARK DRIVE SUITE 400 ROCHESTER NY 14624 POLICY NUMBER CERTIFICATE NUMBER G2571454-4 242742 CERTIFICATE HOLDER TOWN OF CORTLANDVILLE 3577 TERRACE ROAD CORTLAND NY 13045 POLICY PERIOD 03/29/2023 TO 03/29/2024 SCAN TO VALIDATE AND SUBSCRIBE DATE 9/13/2023 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2571454-4, 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. IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY, INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE, VISIT OUR WEBSITE AT HTTPS:INIWW.NYSIF.COM/CERT/CERTVAL.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. 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. NEW YORK STAT�/�,,SUR NCE FUND i Y t* DIRECTOR, INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 173160843 ii oar STANEw workers' CERTIFICATE OF INSURANCE COVERAGE TE Compensation Board NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1. To be completed by NYS disability and Paid Family Leave benefits carrier or licensed insurance agent of that carrier Ia. Legal Name & Address of Insured (use street address only) 1 b. Business Telephone Number of Insured HIGHLAND HOLDINGS LLC 585-615-7054 90 AIRPARK DRIVE #400 ROCHESTER, NY 14624 1c. Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured (Onlyrequired if coverage is specifically limited to 522414777 certain locations in New York State, i.e., Wrap -Up Policy) 2. Name and Address of Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) ShelterPoint Life Insurance Company Town of Cortlandville 3577 Terrace Road 3b. Policy Number of Entity Listed in Box " 1a" Cortland, NY 13045 DBL677591 3c. Policy effective period 01/01/2023 to 12/31/2024 4. Policy provides the following benefits: © A. Both disability and paid family leave benefits. B. Disability benefits only. ❑ C. Paid family leave benefits only. 5. Policy covers: © A. All of the employers employees eligible under the NYS Disability and Paid Family Leave Benefits Law. B. Only the following class or classes of employers 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 and/or Paid Family Leave Benefits insurance coverage as described above. Date Signed 9/13/2023 By l ff (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 516-829-8100 Name and Title Richard White, Chief Executive Officer IMPORTANT: If Boxes 4A and 5A are checked, and this form is signed by the insurance carrier's authorized representative or NYS Licensed Insurance Agent of that carrier, this certificate is COMPLETE. Mail it directly to the certificate holder. If Box 4B, 4C or 5B is checked, this certificate is NOT COMPLETE for purposes of Section 220, Subd. 8 of the NYS Disability and Paid Family Leave Benefits Law. It must be emailed to PAU@wcb.ny.gov or it can be mailed for completion to the Workers' Compensation Board, Plans Acceptance Unit, PO Box 5200, Binghamton, NY 13902-5200. PART 2. To be completed by the NYS Workers' Compensation Board (only if Box 4B, 4C or 5B have been checked) State of New York Workers' Compensation Board According to information maintained by the NYS Workers' Compensation Board, the above -named employer has complied with the NYS Disability and Paid Family Leave Benefits Law(Article 9 of the Workers' Compensation Law) with respect to all of their employees. Date Signed By Telephone Number Name and Title (Signature of Authorized NYS Workeri Compensation Board Employee) Please Note: Only insurance carriers licensed to write NYS disability and paid family leave benefits insurance policies and NYS licensed insurance agents of those insurance carriers are authorized to issue Form DB-120. 1. Insurance brokers are NOT authorized to issue this form. DB-120.1 (12.21) htiiiiu120.i1 (iiiuiiiiiiiii)ii�l�l Additional Instructions for Form D13-120.1 By signing this form, the insurance carrier identified in Box 3 on this form is certifying that it is insuring the business referenced in Box 1 a for disability and/or Paid Family Leave benefits under the NYS Disability and Paid Family Leave Benefits Law. The insurance carrier or its licensed agent will send this Certificate of Insurance Coverage (Certificate) to the entity listed as the certificate holder in Box 2. The insurance carrier must notify the above certificate holder and the Workers' Compensation Board within 10 days IF a policy is cancelled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from coverage indicated on this Certificate. (These notices may be sent by regular mail.) Otherwise, this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent, or until the policy expiration date listed in Box 3c, whichever is earlier. This Certificate is issued as a matter of information only and confers no rights upon the certificate holder. This Certificate does not amend, extend or alter the coverage afforded by the policy listed, nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This Certificate may be used as evidence of a NYS disability and/or Paid Family Leave benefits contract of insurance only --- while the-underlying.policy_is in effect._ Please Note: Upon the cancellation of the disability and/or Paid Family Leave 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 Insurance Coverage for NYS disability and/ or Paid Family Leave Benefits or other authorized proof that the business is complying with the mandatory coverage requirements of the NYS Disability and Paid Family Leave Benefits Law. NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW §220. Subd. 8 (a) The head of a state or municipal 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 and after January first, two thousand and twenty-one, the payment of family leave 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 notwithstanding 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 and after January first, two thousand eighteen, the payment of family leave benefits for all employees has been secured as provided by this article. DB-120.1 (12-21) Reverse Town of Cortlandville Building and Codes Department 3577 Terrace Rd. Cortland, NY 13045 Kevin McMahon Phone: 607-756-7490 NYS Code Enforcement Officer Cell: 607-745-0004 Condemnation Order Property Owner: CNY MHPS LLC Date: 10/06/2023 90 Aimark Drive Suite 400 Rochester, NY 14624 Property Address: 1054 Route 13 Cortland. NY 13045 Tax Map Number: #96.09-04-10.000 To whom it may concern, The building located at the above address is unsafe and cannot be occupied due to structural damage and harmful exposures. I have found it to be unsound and a hazard to the public and surrounding properties as it is currently in an advanced stage of disrepair. The current condition of this structure deems itself an immediate and imminent danger to the public, thereby requiring demolition and removal as soon as practically possible. A demolition permit will be required in addition to the asbestos survey, and demo of a property containing asbestos must be performed by a licensed/certified contractor with current liability and Comp certificates provided. Sincerely, K"44, 71WMalicnv Kevin McMahon NYS Code Enforcement 607-745-0004 CERTIFICATE OF LIABILITY INSURANCE I °A4rzD;Za23"Y' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER I CONTACT Michael G. Montag Insurance Agency, Inc. PHO E FAx 1745 Penfield Road c .n. 800-776-8294 INC. Not: 585-381$173 Penfield NY 14526 AnoaEss mgmprocess(aTmgminsure.com I INSUREFUSI AFFORDING COVERAGE NAIC# License#: 7616131 INSURERA: EVANSTON INSURANCE COMPANY 35378 INSURED HIGHHOL-02 INSURER B : HIGHLAND HOLDINGS LLC 90 AIRPARK DR STE 400 I INSURERC: ROCHESTER NY 14624 I INSURER D: INSURERS: INSURER F: COVERAGES CERTIFICATE NUMBER: 1543876597 REVISION NUMBER: THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. II SRI TYPE OF INSURANCE ADDL SUER POLICY EFF POLICYEXP INSD WVD POUCYNUMBER IMMIODIYYYYI (MMIDUNYYVI I UMnS A X COMMERCIALGENERALLIABILRY 3FF4799, 7/6/2022 7/6/'2023 EACHOCCURRENCE S1,000,000 CLAMS -MADE OCCUR I ETORENTEU REM SES IEe oovnencel S 100,000 MED EXP (Any one person) S 5,000 PERSONAL& ADV INJURY $1,000,000 LIMB APPLIES PER ''G�GE IIN'LAGGREGATE POLICY 0 JEC LOD OTHER: AUTOMOBILE LIABILITY ANYAUTO DINNED SCHEDULED _ AUTOS ONLY AUTOS HIRED P NON-O MED AUTOS ONLY AUTOS ONLY UMBRELLA LIAE OCCUR EXCESS LIAB CLAIMS -MADE DED 1 I RETENTIONS WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANYPROPRIETORPARTNER/EXECUTIVE El NIA OFFICERIMEMBEREXCLUDED? (Mandatary In NH) It yes, desaibe under DESCRIPTION OF OPERATIONS below I GENERAL AGGREGATE S2,000,000 PRODUCTS-COMP/OPAGG $2,000,000 S COMBINED SINGLE LIMIT S (En ardd.rd) BODILY INJURY (Per person) S BODILY INJURY (Per accident) S PROPERTY DAMAGE (Per acadentl S EACHOCCURRENCE AGGREGATE STATUTE I ERA E.L. EACH ACCIDENT S E.L. DISEASE -EA EMPLOYEE S E.L. DISEASE -POLICY LIMIT S OESCRIPTIONOFOPERATIONS/LOCATIONS/VEHICLES (ACORD 101. Additional Remarks Schedule, may be attached if more space is required) DEMO PERMIT CORTLAND ESTATES MHP OFFICE/RENTAL HOUSE CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. TOWN OF CORTLANDNALLE 3577 TERRACE RD AUTHORIZEDREPRESENTATIVE CORTLAND NY 13045 I ©1988.2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD Yoh workers' CERTIFICATE OF INSURANCE COVERAGE STATE Compensation Board DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1. To be completed by Disability and Paid Family Leave Benefits Carrier or Licensed Insurance Agent of that Carrier 1a. Legal Name & Address of Insured (use street address only) HIGHLAND HOLDINGS LLC 90 AIRPARK DR., #400 ROCHESTER, NY 14624 Work Location of Insured (Only required if coverage is specifica/y smiled to certain locations in New York State, i.e.. Wrap -Up Policy) 2. Name and Address of Entity Requesting Proof of Coverage (Entity Bein Listed as the Certificate Holder) Town of I-tlandville 3577 Terrace Rd. Cortland. NY 13045 lb. Business Telephone Number of Insured 5856157054 ic. Federal Employer Identification Number of Insured or Social Security Number 52-2414777 3a. Name of Insurance Carrier Standard Security Life Insurance Company of New York 3b. Policy Number of Entity Listed in Box '1 a" R24242-000 3c. Policy effective period 6/1/2020 to 11/28/2023 4. Policy provides the following benefits: ❑)( A. Both disability and paid family leave benefits. B. Disability benefits only. C. Paid family leave benefits only. 5. Policy covers: ❑X A. All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law. B. Only the following class or classes of 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 and/or Paid Family Leave Benefits insurance coverage as desT91ed above. Date Signed 1 1 /29/2022 By _ (signature of Insurance carrier's author representalwe or NYS Licensed Insurance Agent of that insurance carder) Telephone Number (212) 355-4141 Name and Title SUPERVISOR-DBL/POLICY SERVICES IMPORTANT: If Boxes 4A and 5A are checked, and this form is signed by the insurance carrier's authorized representative or NYS Licensed Insurance Agent of that carrier, this certificate is COMPLETE. Mail it directly to the certificate holder. If Box 4B, 4C or 58 is checked, this certificate is NOT COMPLETE for purposes of Section 220, Subd. 8 of the NYS Disability and Paid Family Leave Benefits Law. It must be mailed for completion to the Workers' Compensation Board, Plans Acceptance Unit, PO Box 5200, Binghamton, NY 13902-5200. PART 2. To be completed by the NYS Workers' Compensation Board (only if Box 4C or 56 of Part 1 has been checked) State of New York Workers' Compensation Board According to information maintained by the NYS Workers' Compensation Board, the above -named employer has complied with the NYS Disability and Paid Family Leave Benefits Law with respect to all of his/her employees Date Signed By Telephone Number Name and Title (Signature of Authorized NYS Workers' Compensation Board Employee) Please Note: Only insurance carriers licensed to write NYS disability and paid family leave benefits insurance policies and NYS licensed insurance agents of those insurance carriers are authorized to issue Fortin OB-120.1. Insurance brokers are NOT authorized to issue this form. 013-120.1 (10-17) Additional Instructions for Form D13-120.1 By signing this form, the insurance carrier identified in Box 3 on this form is certifying that it is insuring the business referenced in box 1a" for disability and/or paid family leave benefits under the New York State Disability and Paid Family Leave Benefits Law. The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed as the certificate holder in Box 2. The insurance carrier must notify the above certificate holder and the Workers' Compensation Board within 10 days IF a policy is cancelled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from coverage indicated on this Certificate. (These notices my be sent by regular mail.) Otherwise, this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent, or until the policy expiration date listed in Box 3c, whichever is earlier This certificate is issued as a matter of information only and confers no rights upon the certificate holder. This certificate does not amend, extend or alter the coverage afforded by the policy listed, nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Disability and/or Paid Family Leave Benefits contract of insurance only while the underlying policy is in effect. Please Note: Upon the cancellation of the disability and/or paid family leave 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 anew Certificate of NYS Disability and/or Paid Family Leave Benefits Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Disability and Paid Family Leave Benefits Law. DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW §220. Subd. 8 (a) The head of a state or municipal 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 and after January first, two thousand and twenty-one, the payment of family leave 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 notwithstanding 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 and after January first, two thousand eighteen, the payment of family leave benefits for all employees has been secured as provided by this article. DB-120.1 (10-17) Reverse //"1\ NYSIF New York State Insurance Fund ^ ^ A A ^ A 522414777 PO Box 66699, Albany, NY 12206 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE DURNAN GROUP INC PO BOX 390 ROCKVILLE CENTRE NY 11571 POLICYHOLDER HIGHLAND HOLDINGS LLC 90 AIRPARK DRIVE SUITE 400 ROCHESTER NY 14624 POLICY NUMBER CERTIFICATE NUMBER G2571 454-4 1 242742 CERTIFICATE HOLDER TOWN OF CORTLANDVILLE 3577 TERRACE ROAD CORTLAND NY 13045 POLICY PERIOD 03/29/2023 TO 03/29/2024 SCAN TO VALIDATE AND SUBSCRIBE DATE 4i20/2023 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2571454-4, 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. IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY, INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE, VISIT OUR WEBSITE AT HTTPS:/IWWW.NYSIF.COM/CERT/CERTVAL.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. 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. NEW YORK STAT�SNCE FUND V%/ DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 173160843 U-26.3