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14-7530 TOWN OF WAPPINGER Zoning Administrator ~�\\ Barham Roberti ;A� TOWN St'P ERV ISO SECRETARY TO ZONING BOARD ' Barbara Gutzler Sue Rase TOWN BOARD ZONING BOARD APPEALS William H. Beale Howard J.Prager , Chairman \\ I .,Vincent Bettina PeterCasella �' %Iich lKczrnki Peter Galotli --' Michael F:uzmicz Bob Johnston ZONING BOARD OF APPEALS Brian Rexhouse 20 MIDDLEBUSH ROAD WAPPINGERS FALLS.NY 12590 Phone SM-297-6256 X122 F. 845-297-0579 E-Mall sr0.f[HoN'r rA sPP ag11 u1 July 23, 2014 To: Joseph Paoloni Town Clerk From: Sue Rose, Secretary Town of Wappinger Zoning Board of Appeals Re: Edith & James Rawley Appeal No. 14-7530 Attached you will find the original Application/Decision & Order for Edith & James Rawley, 19 Booth Blvd. Tax Grid No. 6056-03-462505. 1 would appreciate it if you would file these documents. Attachments cc: Edith & James Rawley Town File Building File Jim Horan q J��ti PptNG� TOWN OF WAPPINGER P.O. BOX 324 - 20 MIDDLEBusH ROAD WAPPINGERS FALLS, NY 1 2590 i - - Zoning Board of Appeals Office: 845.297.1373 — Fax: 845.297 4558 Zoning Enforcement Officer Office: 845.297.6257 www.townofwa ppinger.us Application for an Area Variance Appeal # � q - 2530 Dated: Or. 04 2014 TO THE ZONING BOARD OF APPEALS, TOWN OF WAPPINGER, NEW YORK: I(We), FdA andF1 T=M RawkY residing at 19 B00+11 B1V4 ' &PP +ers Fallsf , �lew vrk 12540 �-g31- 63).8 (phone), here y appeal to the Zoning Board of Appeals from the decision/action of the Zoning Administrator, dated _, andl do hereby apply for an area variance(s). Premises located at 1`160,74% d Tax Grid # 11 9 Hbz505 Zoning District R40 1. Record Owner of Property Edill Ann Towles Eiii Address 190roYh&vd W�n�tnaa�sFaHs �lewVakt2 4D / Phone Number @y5.-�31- 6 {{-- Owner Consent: Dated: (1'�. Signature: Printed: " 2. Variance(s) Request: Variance No. 1 I(We) hereby apply to the Zoning Board of Appeals for a variance(s) of the following requirements of the Zoning Code. Sed"Wp 20-31 DWS NGTurcr a' n nnl ?o✓IC fPAulrPaYtevr4 (Indicate Article, Section, Subsection and Paragraph) Required: S' + 15 Applicant(s) can provide: - rr Thus requesting: VOLW&E filt It Iii le NfaM I_ acIA, �, . _ .L ja.,o rsMF z, P To allow: P !/i.1 st,or, oiz TOo'O2?ZeA-AAV0 `3Ru') 1o:4 Town of Wappinger Zoning Board of Appeals Application for an Area V riance Appeal No. -753" Variance No. 2 I(We) hereby apply to the Zoning Board of Appeals for a variance(s) of the following requirements of the Zoning Code. �lA (Indicate Article, Section, Subsection and Paragraph) Required: Applicant(s) can provide: NFA Thus requesting: n To allow: 3. Reason For Appeal (Please substantiate the request by answering the following questions in detail. Use extra sheet, if necessary): A. If your variance(s) is(are) granted, how will the character of the neighborhood or nearby properties change? Will any of those changes be negative? Please explain your answer in detail, j n 1 B. Please explain why you need the variance(s). Is there any way to reach the same result without a variance(s)? Please be specific in your answer. S S+I V r w.AJA nr>} 6e ufil d a YIA vyiMAA noF 0rnv v qp nriun C. How big is the change from the standards set out in the zoning law? Is the requested area variance(s) substantial? If not, please explain, in detail, why it is not substantial. A i1 h fliseradqe haws • 14 C4321ere .+c �+ni eC r (qui eA k. We Aro 1lNfurP W Mn%1 At mn%l ne+ bv vle kkid ec D. If your variance(s) is(are) granted, will the physical environmental conditions in the neighborhood or district be impacted? Please explain, in detail, why or why not. Ne �'he nMlcir Gnylrnn me�}g�(r�rl�t� oro 1(! +14e l!NM O hQD4 M �.+-f.f�a TOW O1)_BA.AA V(4-03 Rev)2 o 4 onng Board Town of Wa Application I ` for an Area atAppeals Appeal No. /Y-�- E. How did your need for an area variance(s) come about? Is your difficulty self-created? Please explain your answer in detail. s m YPt } o f�i�{i rM_ — i� nnF4v Pf1 IA/rfnc in � A� a y,nntz v F. Is your property unique in the neighborhood that Is needs this type of variance? Please explain your answer in detail. Al 110-1 al"doV tip—MMSf No � r r 1� 4. List of attachments (Check applicable information) (� Survey Dated 01-21' '9S7 , Last Revised and Prepared Prepared by O Plot Plan Dated Photos W Drawings Dated O6 03 Z014 VLetter of Communication which resulted in application to the ZBA. (e.g., recommendation from the Planning Board/Zoning Denial) Dated: Letter from Dated: Letter from ( ) other (please list): S. Signature and Verification plication can be deemed complete unless signed below. Please be advised that no ap The applicant hereby states that all information given is accurate as of the date of application. DATED: SIGNATURE ✓ Rant(Appellant DATED: / SIGNATURE (Tf more than one AP ) Towo„_ZaA AAV(4 M 11c1 13 oro FOR OFFICE USE ONLY 1. THE REQUESTED VARIANCE(S) ( ) WILL / (X)WILL NOT PRODUCE AN UNDESIRABLE CHANGE IN THE CHARACTER OF THE NEIGHBORHOOD. 2. ( ) YES / ( )l NO, SUBSTANTIAL DETRIMENT WILL BE CREATED TO NEARBY PROPERTIES. 3. THERE( )IS(ARE) / ( 30 IS(ARE)NO OTHER FEASIBLE METHODS AVAILABLE FOR YOU TO PURSUE TO ACHIEVE THE BENEFIT YOU SEEK OTHER THAN THE REQUESTED VARIANCE(S). 4 THE REQUESTED AREA VARIANCE(S) ( )IS (ARE) / (X)IS(ARE)NOT SUBSTANTIAL. 5. THE PROPOSED VARIANCE(S) O WILL/ (X)WILL NOT HAVE AN ADVERSE EFFECT OR IMPACT ON THE PHYSICAL OR ENVIRONMENTAL CONDITIONS IN THE NEIGHBORHOOD OR DISTRICT. 6. THE ALLEGED DIFFICULTY(X)IS / ( )IS NOT SELF-CREATED. CONCLUSION: THEREFORE,IT WAS DETERMINED THE REQUESTED VARIANCE IS (X) GRANTED ( )DENIED. CONDITIONS/STIPULATIONS: The following conditions and/or stipulations were adopted by resolution of the Board as part of the action stated above: The ZBA voted to grant an eleven foot right side variance for the construction of a 13 x 25 addition; to include extending the living 6 dining room at the first floor level and extend the family roon at the basement level. Where 25 feet was required, the applicant could only provide 14 feet. ( )FINDINGS &FACTS ATTACHED. DATED: _July 22. 2014 ZONING BOARD OF APPEALS TOWN OF WAPPINGER,NEW YORK BY: (Chairman) PRINT: wprag u 6Ek 1543 SAGE S95 539 41=00 W aa 10 .00 SSWG VN _ Z in W Gbf o' Ro W L RNISEO 4gNCN HQ 3'Y �k I� wAOE Rol AL INU+W4.9 I?I /� sl cn 400 y �qS Jl1V��IS C.N �w.•193¢aad� �o JJ 19(. x'69 PAGE 356 �J 9 \D� Lf I� P2 o � I�1 °u � -rI Al N If W W „S 51=51 OO E 10. £ ; 102.00 �uu-t4 BO Bort '195 UD. 2 8 194 RREpk - 0.'1'il RCRES L� COM7009'S E) 15i11.16 AS OF JRV). al, 1989 MAP OF su%JV4 OF w . . , . ..._ ..••� . . .. ...1 Jl ..1.� ._... ✓� `4,��� ���' �7p�i j� . i Rhea t�, ,l �� � , � .., i gp� tl} p ��,i.�l, 1",q 01iT s����. g � �� Re f f� KM13'-O• ITCHEN ROOK ❑� D1t1tN4 o ° ADDITION RAM" uvtN4 ROOM owswom WIPWEB FNI; IBY Y[B �M FLOOR PLAN SOALE! 1/8'= 1'-0' rAv n mm ..w ansuaww... ..eaw.a. �AIE 11E 3.NN1 PRAWIN65 ARE FOR Z0NIN6 FWP05E5 ONLY P REAR ELEVATION APOffM PAVAW peon w.a w eaw aw rw.s +rax r..�d.n ❑❑ UD AWAMWT wre FRONT ELEVATION 5OAL6 I/8'= I'-0' IRMIN55 ARE FOR ZOO&RRF05E5 ONLY L 617.10 AppendLr B Short EnvironmentaLAssessment Fornr Instructions for Colnuletini Part 1 -Project Information. The applicant or project sponsor is responsible for the completion of Part L Responses become part of the application for approval or funding,are subject to public review,and maybe subject to further verification. Complete Part 1 based on information currently available. Ifadditional research or investigation would be needed to fully respond to any item,please answer as thoroughly as possible based on current information. Complete all items in Pan 1. You may also provide any additional information which you believe will be needed by or useful to the lead agency; attach additional pages as necessary to supplement any item. Part I-Project and Sponsor Information Name of Action or Project: Rawley AAA i0vt Project Location(describe,and attach a location map): 19 Boo+hNvd•- W to ers Ws Kew Jork 115go BriefDescriptian of Proposed Action: t Construct 13'X25' agile s4vyi ito McW-le C�x+eyvllnrj IMri9 E dlnlns room A firs} -Noor and ufr� A •Fatmlfy room a4 base ne*lf I evel Name of Applicam or Spansor: Telephone: .3 wh and Tames Rawl E-Mail: Add ess: l9 8�fh B1ud- iGINIM01A 35e'101.COM Cirv/PO: State: Zip Code: Nlit pt Falls N`( 12,590 1. Does the proposed action only involve the legislative adoption at a plan,local law,ordinance, NO YES administrative rule,or regulation? If Yes,attach a narrative description ofthe intent of the proposed action and the environmental resources that may be affected in the municipality and proceed to Part 2. If no,continue to question 2. z 11 2. Does the proposed action require a permit,approval or funding from any other governmental Agency? NO YES If Yes,list agency(s)name and permit or approval: El o� Wa I er b% :Ijdin D ar+mevlt 3.a.Total acreage of the site of the proposed acti ? 0,}41 acres b.Total acreage to be physically disturbed? 0.01 acres C.Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor? _Q•}L{Lacres 4. Check all land uses that occur on,adjoining and near the proposed action. ,,JJ ❑Urban ❑Rural(nonagricWture) ❑Industrial ❑ L�J Commercial Residential(suburban) ❑Forest ❑Agriculture []Aquatic ❑Other(specify): ❑Parkland Page 1 of 4 5. Is the proposed action, NO YES N/A a.A permitted use under the zoning regulations? ❑ ❑ b. Consistent with the adopted comprehensive plan? ❑ M ❑ 6. Is the proposed action consistent with the predominant character of the existing built or namml NO YES landscape? ❑ 7. Is the site of the proposed action located in,or does it adjoin,a state listed Critical Fnvironmmral Area? NO YES If Yes,identify: � ❑ S. a.Will the proposed action result in a substantial increase in traffic above present levels? NO YES b.Are public transportation service(s)available at or near the site of the proposed action? 11 13 c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed anion? 11 9.Does the proposed action meet or exceed the state energy code requGements? NO YES L`the proposed action will exceed requirements,describe design features and technologies: lam' F-1 IJ 10. Will the proposed action connect to an existing public/private water supply? NO YES If No,describe method for providing potable water: ❑ 5- 11.Will the proposed action connect to existing wastewater utilities? NO YES If No,describe method for providing wastewater treatment: ❑ IT 12. a.Does the site coatain a structure that is listed on either the State or National Register of Historic NO YES Places? ❑ b.1s the proposed action located in an archeological sensitive area? 13.a.Does any portion of the site of the proposed action,or lands adjoining the proposed action,contain NO YES wetlands or other waterbodies regulated by a federal,state or local agency? ❑ b. Would the proposed action physically alter,or encroach into,any existing wetland or waterbody? ❑ If Yes,identify the wetland or waterbody and extent of alterations in square feet or acres: 14. Identify the typical habitat types that occur on,or are likely to be found on the project site. Check all that apply: ❑Shoreline El Forest El Agricultural/grasslands ❑Early raid-successional ❑ Wetland El urban O Suburban 15.Does the site of the proposed action contain any species ofanimal,or associated habitats,listed NO YES by the State or Federal government m threatened or endangered? ElI6.Is the project site located in the 100 year flood plain? NO YES 17.Will the proposed action create storm water discharge,either from point or non-point sources? NO YES If Yes, a.Will storm water discharges flow to adjacent properties? ❑NO []YES ❑ b.Will storm water discharges be directed to established conveyance systems(runoff and storm drains)? lfYes,briefly describe: []NO ❑YFS Page 2 of 4 18.Does the proposed action include construction or other activities that result in the impoundment of NO YES water or other liquids beg, retention pond,waste lagoon,dam)? If Yes,exaiv purpose and size: J ❑ 19.Has the site of the proposed action or an adjoining property been the location of an active or closed NO YES solid waste management facility? If Yes,describe: ^/ ❑ 20.Has the site of the proposed action or an adjoining property been the subject of remediation(ongoing or NO YES completed)for hazardous waste? If Yes,describe ❑ I AFFIRM THAT THE INFORNIATION PROVIDED ABOVE IS TRUE AND ACCIIRATE TO THE BEST OF MY KNOWLEDGE Applicant/sponsor name: t✓e i/ /'Qr/ Date Signature' Part 2-Impact Assessment. The Lead Agency is responsible for the completion of Part 2. Answer all of the following questions in Part 2 using the information contained in Part I and other materials submitted by the project sponsor or otherwise available to the reviewer. When answering the questions the reviewer should be guided by the concept"Have my responses been reasonable considering the scale and context of the proposed action?" No,or Moderate small to large impact impact May may occur occur 1. Will the proposed action create a material conflict with an adopted land use plan or zoning ❑ ❑ regulations? 2. Will the proposed action result in a change in the use or intensity of use of land? ❑ ❑ 3. Will the proposed action impair the character or quality of the existing community? ❑ ❑ 4. Will the proposed action have an impact on the environmental characteristics that caused the establishment of a Critical Environmental Area(CEA)? El E] 5. Will the proposed action result m an adverse change in the existing level of traffic or El E]affect existing infrastructure for mass transit,biking or walkway? 6. Will the proposed action cause an increase in the use of energy and it fails to incorporate ❑ ❑ reasonably available energy conservation or renewable energy v portunities? 7. Will the proposed action impact existing' ❑ ❑ a public/private water supplies? b.public/private wastewater treatment utilities? 8. Will the proposed action impair the character or quality of important historic,archaeological, ❑ ❑ architectural or aesthetic resources? 9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands, ❑ ❑ waterbodies,groundwater, air quality,flora and fauna)? Page 3 of 4 Aheakhl Moderate fo large impact M may occur I0. Will the proposed action result in an increase in the potential for erosi ❑ problems? 11. Will the proposed action create a hazard to environmental resources or El 7 Part 3-Determinadon of significance. The Lead Agency is responsible for the completion of Part 3. For every question in Part 2 that was answered"moderate to large impact may occur",or if there is a need to explain why a particular element of the proposed action may or will not result in a significant adverse environmental impact,please complete Part 3. Part 3 should,in sufficient detail,identify the impact,including any measures or design elements that have been included by the project sponsor to avoid or reduce impacts. Part 3 should also explain how the lead agency determined that the impact may or will not be significant.Each potential impact should be assessed considering its setting,probability of occurring, duration,irreversibility,geographic scope and magnitude. Also consider the potential for short-term,long-term and cumulative impacts. Check this box if you have determined,based on the information and analysis above,and any supporting documentation, that the proposed action may result in one or more potentially large or significant adverse impacts and an environmental impact statement is required. I❑ Check this box if you have determined,based on the information and analysis above,and any supporting documentation, that the proposed action will not result in any significant adverse environmental impacts. Name of Lead Agency Date Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signature of Responsible Officer u Lead Agency Signature of Preparer(if different from Responsible Officer) PRINT page 4 of 4 Town of Wappinger 20 Middlebush Rd. Wappingers Falls, NY 12590 (845) 297-6256 To: Rawley, James SBL: 6056-03-462505 Rawley. Edith Date of This Notice:5/2 312 01 4 19 Booth Blvd Zone: R40 Application #: 33114 For Property Located at: 19 Booth Blvd Your application to: CONSTRUCT 13' X 25' ADDITION -TO INCLUDE EXTENDING LIVING & DINING ROOM AT IST FL. LEVEL & EXTEND FAMILY ROOM AT BASEMENT LEVEL. is denied for the following deficiency under Section 240-37 of the Zoning Laws of the Town of Wappinger Where the side yard setback is 25', the applicant can only provide 14'. o .'Accessory Structures must comply with all minimum yard setback requirements for buildings, but in no case shall they be permitted in the front yard." Does NOT MEET dimensional requirement for Zone. o"This zoning district has a front yard requirement of seventy-five feet (75')from a state or County road." As per code Section 240-26, which states: " The use of tents, trailers and mobile homes for permanent o dwelling purposes shall not be permitted in any district except as permitted and regulated in Section 240-51, Mobile home park, of this chapter.." REQUIRED: WHAT YOU CAN PROVIDE: REAR YARD: ft. ft. SIDE YARD (LEFT): ft. ft. SIDE YARD (RIGHT): r�J' —R _— I L ft. FRONT YARD: ft. ft. SIDE YARD (LEFT): ft. ft. SIDE YARD (RIGHT): ft. ft. You have the right to appeal this decision to the Zoning Board of Appeals within 60 days of the date of this letter. The Zoning Board of Appeals meets the second and fourth Tuesday of the month. The area variance appeal will require at least two meet ngs, one for discussion and one for a Public Hearing. The required forms can be obtained at this office. Very truly, B araRoberti Zoning Administrator Town of Wappinger \ Robert Lutz, CAPS toTEL:845A85 8343 r FAX,Bas Passes bob@DBSremodelcorn NAPPINGER BUILDING DEPARTMENT . - - -- ` idlebush Road, Wappingers Falls, N.Y. 12590 telephone: 845-297-6256 fax: 845-297-0579 www.D89remodel.com TION FOR BUILDING PERMIT APPLICATION TYPE: Residential �. E: DATE: Ji--a�-� O New Construction O Commercial APPL#: 33// PERMIT# X Renovation/Alteration 0Multipl�t-e Dwelling l,, GRID: IS56VI-6056-03-46250.,-M00 .APPLICANT NAME: Edl+h clay RaN/LGy ADDRESS: 19 BOPFh B)Vd. WapPInjer5 ils, NY 1259a n,,'' TEL#: 845-S31,632? CELL: 945 224 }151 FAXX#: � F,-MAIL: IpV�0uvl'Lft NAME OWNER OF BUILDING/LAND: Cd b. JaRbAeV 'PROJECT SITE ADDRESS': 19 BOafh Blvd. - Wap' inge(S S 1 MY 1200 MAILING ADDRESS: A 9/mA Alvd h1alOf logr(�l.t , N )2540 TEL#: ¢g5.631 &32.8 CELL: 91)5.22q.�151 FAX#: a — E-MAIL:,"a35Rao1-tbm BUILDER/CONTRACTOR DOING WORK: r� /� __L y� COMPANY NAME: DBS Reriacld /Robes's W4 0pprjmjs j�'• G - I I�5 .ADDRESS. 9N FfeedOrn Pjaitis RJ 1&4t N, - Pouah�le IAIY 12603' 7 TEL#: .uxCt s3N 3 CELL. FAX#:g45 g:&jqj E-MAIL: h�bbP (m,MpGP�,60M DESIGN PROFESSIONAL NAME: Ddv Id Freeman , Archltecf }, ILL#: 645.4525359CELL: -- FAX#: FqS,452.5339E-MAIL: davidPdfarchl.Col'1'1 APPLICATION FOR: Colss Y'a d Addifion a+ f side, o; klouse P X��nr�e� �a rri tl� enom faasC/YIP.n4 lPXZ�. Addition ex fends info Ton-ldil Set back Il' and will C4[A.We A 1100atICe Peow,r) l SETBACKS: FRONT: W't/ REAR: 661 �- L-SIDEYARD: Dl.t- R-SIDEYARD: }J1}� 'l- SIZE OF STRUCTURE: 13'X20,2,0—h5' +/- 0r�5 ESTIMATED COST: * -+5,f)00 TYPEOFySE: F�raynil /Ae"idgnclid NON-REFUNDABLE APPL.FEE:�V PAID ON:S'Z" (CHECK#VI ,, `,I RECEIPT#: 21 BALANCE DUE: PAID ON: CHECK# RECEIPT#: APPROVALS: ZONING ADMINISTRATOR: yy FIRE INSPECTOR: O Ap need 4 Denie atAp need aft ' /1 O Approved O Denied Date: SK.m.re of Applicant Signature of Building Inspector U BER 1593 9gGE 895 x+ S 390 yQ-00 VV a� 10 .00 DENIED ZONING ADMINISTRATOR z ;}iAY 3 3 201 F-36t RCI$ED 0.PHCN NQ 1� PROP05Ep _ e T oal ao� ,k t+� I ` SE Ace 701 I �I SOOSAL I O iaVH4.9 Iol \� En d°0 Q �w�.va aa2t . pop 190 SWVE tJ Ll W n1 L Ma fD I Iq ''°o w II w S 51"51-000 E 10.00 �'al4' E r IOa.00 U iC B " B 3 A 200 194 N6 194 ga.E�l : O.'1V1 RCRES i) GOhYCOURS COSNG RS OF 3*). al, 198 MAP OF SU9%\Jcl4 oG STATE OF NEW YORK WORKER'S COMPENSATION BOARD 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 Carne, Ia.Legal Name and Address of insured(use street address only) To.Business Telephone Number-of Insured DUTCHESS BUILDING SPECIALISTS, INC. DBA DUTCHESS DECKING tc NYS Unemployment Insurance Employer Registration Number of Insured 488 FREEDOM PLAINS R OAD, SUITE 130 POUGHKEEPSIE, NY 12603 td.Federal Employer Identification Number of Insured or Social Security Number 141735231 2 Name and Address of the Entity requesting Proof of Coverage 3a.Name of l murance Carrier (Entity being listed as the certificate Holder) The First Rehabilitation Life Insurance Town of Wappinger Company of America 3b.Policy Number of Entity lived in boa"tan% Building Dept DBL423888 20 Middlebush Rd 3b Poliryeffectivepermck. Wappingers Falls NY 12590 01/01/2014 to 12/31/2014 4.Polity covers: a. ❑✓ All of meemployer's employees eligible Under the New York Disability Benefits Law b. —j Only the folimvirg doss w classes of trle employar's employees: Under penaltyof perjury,I certify that I am an autbmized representative or licensed agem df the insurance carrier referenced above antl thatme,named insured has NYS Disability Berefits imurUme coverage as described above. Dau signed 3/11/2014 By ISynturt of imunnce mier's aumorizm rtpresmtetive os NYS Licensed Imvncc Agan[of mat insurancc cartierl Telephone Number 516-829-8100 Tide Chief Executive Officer IMPORTANT:Ifbm^aa'is mocked ma thlsform is signed by an,Insurance uma'samllwhed representative orNYS Ucrosed insuran¢Agerr of thal®riner,Mismtifi®teis COMPLETE.Mailitdirmlymmecertlf tehold . (floor"ab'h checked mis ccrdnute h NOT COMPLETE fes the purposes of Section 220.S.W.S of me Disability Benefih Law. Is must be hafted far completion to the Wei Compansatlan Board,OB Plans Accepnme Unit,at Park Strain,Minims,NY 1M. PART 2. To be completed by NYS Worker's Compensation Board (Only if box"4b"of Part 1 has been checked) State of New York Worker's Compensation Board According to information maintained by Ne NYS Wnker's Campensalionaa,lyd,me W ovenmel enpioyerhas ran shed wine the NYS Diubllity Benefini La-with respect tcall of hislhttemployees. Date Signed By ISigmtue of NYS Wwkc'z Canpmsehm 9wrtl Employee) Telephone Number Title Please Now.Only insurance caniere licensed to write NYS Disability Bercnts insurance policies and NYS Licensed Insurance Agents of those insurance carriers are authorized to issue Form DB-120.1.Insurance brokers are NOT aumodzed to issue this form 06120.1 (5-n6) STATE OF NEW YORK WORILEH'S COMPENSATION BOARD CERTIFICATE OF NYS NV0PJMRS' COMPENSATION INSURANCE COVEPUGE la Legal NameandaMresv of Ivsared(lbssweetaT141735231 iness Tele'lea,Nombes of Ina111M Doss].Building S esssovs IleS.5-83l3 488FIeedan Phtlta Roel S e 130 Por�BJtLeeprie.NF 1' 03AMG WS Utmemploymeot msvrmce Employer lstr ed.Neither of In.ed DBA:Dmchea�Destse, eral Employer Iodeatl9esdoo Number a WurM coma Secmlty Number 5231Po 2.Name and Addiasof the Evdty Ralvestivg Plots Ol Covn'age 3a.Name oflmusautt Cmtim' (Eutlw Btlug Lamda me Cestlmnm Hddes) Rochdale lost , eCmmwry Town of W'aPphgma BWduly Dep[ 20 Nfasti.mh Road 3b.WC33 Numher d mtlry IlstMiv hoz"l a'": W:ryhalrgers F:dis.M"L'i90 RWC33119.i! 3<Polity efe Live palod: l,LMl3to PI,'MI5 .id.The Propdemr.Parmert or Ezrcutive OlBms are: r mdvdM(oily dvcL Wxif:stl pamtac oBcem meloded) r all ezduAM or cumin pnrmax'ommz¢tladM Thus testifies stmt file hstvm ie,eerie oboated above ht bei"T'bees.the badness referenced above to bot"la"for workers' c—Plall nts'mtder the New York State Workers'Cmnpensa6ol,Law.(To use this to=,New York(NY)mrut be listed ander Iters 3A mI file INFORMATION PAGE of the workers'cmnpersaRonhs'Irtarme pohcy).The btstvmme Carrier 0rihs hcersed aead will send flus Cershoofimt of hcsmmme to the entity)fisted above w the certificate holds m box"2". The bsrvm¢a Corr ienrillalsosmnfiNm above cerhficote lraldvr'Who,l0 dm's lF apolier is cmmelad rhre rono,w;... nt jyre o tl ' 30d sIF Ur. . a orsotl . Uru vwpnnnest fprarn it ties cmma)lir pots akar mte tl .v.n redfran tharnnmrs c emdi osdol,tills Cerfifrcate 077 . eoonesaa be sent bi reglor toad Othantue tills Carmfecnt is lahljt,are baa"per Nrtafonn is rryproedb, Al"nrsrmrvma carrier or its heenwd avers or rarUl thepoHn erperahorr date listed hr bat 3 ,nhfelxser is eordii, Please Note:Upon the Caneellatba of the workers'computation polky lodicated on thisfterm,Y the bad..tantrum to Im named on a permit,Wilma,or contract heated by a certMgte holder,the busicese msrrtpre0de that corUHote holder with a new Certificate of R'orkers'Compenattivn Coverage or other authorised proof that the buHn in Is mmplylmg with the mandatory coverage requirements of the NewY ork State Workers'Compensation Law. Under penalty of perjury,I certify doo l am an mad razed reprom mmtive or ReenmA agent of the Immense©mer referenced above and that the marred Insured baa the reveruge as depleted on tldaform. .1P}aovedBy: Horny C.&Ney (P nines. ef-doessaw ir kessidavmt duaunee mda) Ael Apif'42Vgoved B>': 113,2014 (srmmar) m..l Tike: UoderwriMg Shwas,, T.Ii,h-eN.-Ree fieffi lregrmae —w41medssm1 utv.mwamur:ceae34me PI tliee:QJY»xrarn caulenw6fMtllcwMggmhama6M»m6brsre tFe GI05.]Ar>rr.Lurvmrn EmhnareNOToudamedb use tt C-1 K2(9-0')