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HomeMy WebLinkAbout20211162 115 Ballston Area Variance Application k*HANDWRITTEN APPLICATIONS WILL NOT BE ACCEPTED** ' ""_' '"----` ,Kr 0G4: n CITY OF SARATOGA SPRINGS (Application#) c �' •,' s ZONING BOARD OF APPEALS CITY HALL-474 BROADWAY ( '<"� % (Date received) SARATOGA SPRINGS,NEW YORK 12866-2296 1 TEL:518-587-3550 X2533 '+`0'hPORa1Eo ``''h www.saratoga-springs.org (Project Title) APPLICATION FOR: INTERPRETATION,USE VARIANCE, Check If PH Required AREA VARIANCE AND/OR VARIANCE EXTENSION Staff Review APPUCANT(s)* OWNER(S)(ll not applicant) ATTORNEY/AGENT Saxton Sign Corp Golub Corp/Market 32 Name 1320 rt9 461 Notts St Address Castleton NY 12033 Schenectady NY 12035 Phone 518-754-2026 / 518-355-50(/ / dkatz@saxtonsign.com Email Primary Contact Person: QApplicant ❑Owner attorney/Agent *An applicant must be the property owner,lessee,or one with an option to lease or purchase the property in question. Applicant's interest in the premises: 0 Owner 0 Lessee 0 Under option to lease or purchase PROPERTY INFORMATION 115 Balston Ave I.Property Address/Location: Tax Parcel No.: - (lor example:165.52—4—37) 2. Date acquired by current owner: 3.Zoning District when purchased: Commercial 4. Present use of property: 5.Current Zoning District: 6. Has a previous ZBA application/appeal been filed for this property? 0 Yes(when? For what? ) 12 No 7. Is property located within(check all that apply)?: 0 Historic District 0 Architectural Review District 0 500'of a State Park,city boundary,or county/state highway? Installation of Illuminated Directional on Existing Light post 8. Brief description of proposed action: 9. Is there an active written violation for this parcel? 0 Yes P1 No 10. Has the work,use or occupancy to which this appeal relates already begun? 0 Yes 0 No 11. Identify the type of appeal you are requesting(check all that apply): 0 INTERPRETATION(p.2) 0 VARIANCE EXTENSION(p.2) 0 USE VARIANCE(pp.3-6) 12 AREA VARIANCE(pp.6-7) Revised 01/202 1 ZONING BOARD OF APPEALSAPPLICATION FORM PAGE2 INTERPRETATION—PLEASE ANSWER THE FOLLOWING(add additional information as necessary): I. Identify the section(s)of the Zoning Ordinance for which you are seeking an interpretation: zoning variance for Directional sign relief(4.5 square feet and 13.5 feet above grade). Section(s) 2. How do you request that this section be interpreted? 3. If interpretation is denied,do you wish to request alternative zoning relief? 121Yes ❑No 4. If the answer to#3 is"yes,"what alternative relief do you request?❑Use Variance 0 Area Variance EXTENSION OF A VARIANCE—PLEASE ANSWER THE FOLLOWING(add additional information as necessary): I. Date original variance was granted: 2. Type of variance granted? 0 Use 0 Area 3. Date original variance expired: 5. Explain why the extension is necessary.Why wasn't the original timeframe sufficient? When requesting an extension of time for an existing variance,the applicant must prove that the circumstances upon which the original variance was granted have not changed. Specifically demonstrate that there have been no significant changes on the site, in the neighborhood,or within the circumstances upon which the original variance was granted: Revised 01/2021 ZONING BOARD OF APPEALS APPLICATION FORM PAGE 3 USE VARIANCE—PLEASE ANSWER THE FOLLOWING(add additional information as necessary): A use variance is requested to permit the following: For the Zoning Board to grant a request for a use variance,an applicant must prove that the zoning regulations create an unnecessary hardship in relation to that property. In seeking a use variance,New York State law requires an applicant to prove all four of the following "tests". I. That the applicant cannot realize a reasonable financial return on initial investment for any currently permitted use on the property. "Dollars&cents"proof must be submitted as evidence.The property in question cannot yield a reasonable return for the following reasons: A. Submit the following financial evidence relating to this property(attach additional evidence as needed): I)Date of purchase: Purchase amount: $ 2)Indicate dates and costs of any improvements made to property after purchase: Date Improvement Cost 3)Annual maintenance expenses:$ 4)Annual taxes:$ 5)Annual income generated from property:$ 6)City assessed value: $ Equalization rate: Estimated Market Value:$ 7)Appraised Value:$ Appraiser: Date: Appraisal Assumptions: Revised 01/2021 ZONING BOARD OFAPPEALSAPPLICATION FORM PAGE 4 B. Has property been listed for sale with ❑Yes If"yes",for how long? the Multiple Listing Service(MLS)? LONo I)Original listing date(s): Original listing price:$ If listing price was reduced,describe when and to what extent: 2)Has the property been advertised in the newspapers or other publications? EYes ❑No If yes,describe frequency and name of publications: 3)Has the property had a"For Sale"sign posted on it? DYes ❑No If yes,list dates when sign was posted: 4)How many times has the property been shown and with what results? 2. That the financial hardship relating to this property is unique and does not apply to a substantial portion of the neighborhood. Difficulties shared with numerous other properties in the same neighborhood or district would not satisfy this requirement.This previously identified financial hardship is unique for the following reasons: Revised 01/2021 ZONING BOARD OFAPPEALSAPPLICATION FORM PAGE 3. That the variance, if granted,will not alter the essential character of the neighborhood. Changes that will alter the character of a neighborhood or district would be at odds with the purpose of the Zoning Ordinance.The requested variance will not alter the character of the neighborhood for the following reasons: Multiple Signs Currently in vacinity.Proposal will ease Traffic Safety Concerns 4. That the alleged hardship has not been self-created.An applicant(whether the property owner or one acting on behalf of the property owner)cannot claim"unnecessary hardship"if that hardship was created by the applicant,or if the applicant acquired the property knowing(or was in a position to know)the conditions for which the applicant is seeking relief.The hardship has not been self-created for the following reasons: Due to the increase in use of Grocery Pick up,the client is in need of expantion of current area to accomadeate,and safetly direct the increase of traffic for Grocery Pick up Revised 01/2021 • ZONING BOARD OFAPPEALS APPLICATION FORM PAGE 6 AREA VARIANCE—PLEASE ANSWER THE FOLLOWING(add additional information as necessary): The applicant requests relief from the following Zoning Ordinance article(s) Dimensional Requirements District Requirement Requested Other: To grant an area variance,the ZBA must balance the benefits to the applicant and the health,safety,and welfare of the neighborhood and community,taking into consideration the following: I. Whether the benefit sought by the applicant can be achieved by other feasible means. Identify what alternatives to the variance have been explored(alternative designs,attempts to purchase land,etc.)and why they are not feasible. This is deemed best methos for visibility for traffic safety 2. Whether granting the variance will produce an undesirable change in the character of the neighborhood or a detriment to nearby properties. Granting the variance will not create a detriment to nearby properties or an undesirable change in the neighborhood character for the following reasons: No undesireable change will occur if allowed Revised 01/2021 ZONING BOARD OFAPPEALS APPL/CATION FORM PAGE 7 3. Whether the variance is substantial. The requested variance is not substantial for the following reasons: No,adding sign to an existing Light Post 4. Whether the variance will have adverse physical or environmental effects on neighborhood or district. The requested variance will not have an adverse physical or environmental effect on the neighborhood or district for the following reasons: No. Impact has been created previously 5. Whether the alleged difficulty was self-created(although this does not necessarily preclude the granting of an area variance).Explain whether the alleged difficulty was or was not self-created: No,the need for Grocery Pick up was not created by tenant Revised 01/2021 ZONING BOARD OF APPEALSAPPLIC4T/ON FORM PAGE 8 • DISCLOSURE Does any City officer,employee,or family member thereof have a financial interest(as defined by General Municipal Law Section 809)in this application? 0 No 0 Yes If"yes",a statement disclosing the name,residence and nature and extent of this interest must be filed with this application. APPLICANT CERTIFICATION I/we,the property owner(s),or purchaser(s)/lessee(s)under contract,of the land in question,hereby request an appearance before the Zoning Board of Appeals. By the signature(s)attached hereto, I/we certify that the information provided within this application and accompanying documentation is,to the best of my/our knowledge,true and accurate.I/we further understand that intentionally providing false or misleading information is grounds for immediate denial of this application. Furthermore, I/we hereby authorize the members of the Zoning Board of Appeals and designated City staff to enter the property associated with this application for purposes of conducting any necessary site inspections relating to this appeal. 11/17/21 Date: (applicant signature) Date: (applicant signature) If applicant is not the currently the owner of the property,the current owner must also sign. 11/17/21 Owner Signature: Date: Owner Signature: Date: Revised 01/2021 \\zKtoc sf CITY OF SARATOGA SPRINGS `,' ii, ZONING BOARD OF APPEALS o 4 yi a cn 4 Cufy Hall. - 474 Broadway � :rr.ry 1 ' - Sarapfoga-Spriktgy, New-York.12866 ',VeoRAT�D ` � S `p T518-587-3550 X2533 9-3Sin'i"9yo'9 INSTRUCTIONS APPEAL TO THE ZONING BOARD FOR AN INTERPRETATION,USE VARIANCE,AREA VARIANCE AND/OR VARIANCE EXTENSION APPLICATION REQUIREMENTS 1. ELIGIBILITY:To apply for relief from the City's Zoning Ordinance,an applicant must be the property owner(s) or lessee,or have an option to lease or purchase the property in question.The Zoning Board of Appeals(ZBA) shall not accept any application for appeal that includes a parcel which has a written violation from the Zoning and Building Inspector that is not the subject of the application. 2. COMPLETE SUBMISSIONS: Applicants are encouraged to work with City staff to ensure a complete application. The ZBA will only consider properly completed applications that contain 1 original and 1 digital version of the following: ❑ Completed application pages I and 8,the pages relating to the requested relief(p. 2 for interpretation or extension, pp. 3-5 for use variance, pp. 6-7 for area variance),and any additional supporting materials/ documentation. **HANDWRITTEN APPLICATIONS WILL NOT BE ACCEPTED** ❑ Completed SEQR Environmental Assessment Form—short or long form as required by action. http://www.dec.ny.gov/docs/permits_ej_operations_pdf/seafpartone.pdf ❑ Detailed "to scale"drawings of the proposed project—folded and no larger than 24"x 36". Identify all existing and proposed structures, lot boundaries and dimensions,and the relationship of structures to the lot dimensions.Also, include any natural or manmade features that might affect your property(e.g., drains, ponds,easements, etc.). ❑ Photographs showing the site and subject of your appeal,and its relationship to adjacent properties. 3. APPLICATION FEE (NON-REFUNDABLE): Make checks payable to the "Commissioner of Finance". REFER TO THE CURRENT FEE WORKSHEET INCLUDED IN THIS DOCUMENT. Check City's website(www.saratoga-springs.org)for meeting dates. Revised 01/2021 ZONING BOARD APPEAL APPLICATION INSTRUCTIONS PAGE 2 PUBLIC HEARING ADVERTISEMENT The Zoning Board of Appeals is required to hold a public hearing on each submitted application within ninety(90) days from when it is determined to be properly complete by City staff. City staff will prepare a legal notice for the public hearing and arrange to have the public hearing announcement printed in the legal notice section of a local publication at least 5 days before the hearing. PROPERTY OWNER NOTIFICATION Applicants are required to mail a copy of the public hearing legal notice to all property owners within the following distances from the boundaries of the land in question: Type of variance Distance for property owner notification Use variance 250 feet Area variance&Interpretation 100 feet This notice must be sent at least 7 days but not more than 20 days before the date of the public hearing. City staff will email a copy of the"property owner notification letter"to the applicant.The applicant must then send the notification letter to the nearby property owners.Applicants may not include any other materials in this mailing. The mailing must be certified by the U.S. Post Office. Prior to the public hearing,applicants must present the Post Office "certificates of mailing"to the ZBA. If"certificates of mailing" are not presented prior to the hearing,the hearing will be cancelled. Revised 01/2021 2021 LAND USE BOARD FEE WORKSHEET OPED Fees Type 2021 Fee Application to Zoning Board of Appeals[1][2] TOTAL #VARIANCE Use Variance $1100+$50/app Area Variance-Residential $275/var+$50/app+$125 each add'I variance Area Variance-Multi-Family,Comm,Mixed-Use $660/var+$50/app+$200each add'I variance Interpretations $550+$50/app Post-Work Application Fee Add 50%App fee+$50/app Variance extensions 50%ofAppfee+$50/app Application to Design Review Commission[1] TOTAL #STRUCTURE Demolition ( 15385 Residential Structures Principal $55 Accessory $55 Extension $35 Modification $55 Multi-Family,Comm,Mixed-Use Structures Sketch $165 Principal $550 Extension $200 Modification $330 Multi-Family,Comm,Mixed-Use Accessory,Signs,Awnings Principal $140 Extension $75 Modification $140 Post-Work Application Fee Add 50%App fee Application to Planning Board[1] TOTAL *STRUCTURE Special Use Permit[2] $990+$50/app Special Use Permit-extension $330 Special UsePermit-modification[2] $450+$50/app Site Plan Review-incl.PUD: Sketch Plan $330 Residential $330+$200/unit Residential-extension $200 Residential-modification $400 Non-residential $660+$130/1000sf Non-Residential-extension $300 Non-Residential-modification $650 Subdivision-incl.PUD: TOTAL *LOTS Sketch Plan I � 15330 Preliminary Approval[2] Residential:1-5 lots $660+$50/app Residential:6-10 lots $990+$50/app Residential:11-20 lots $1320+$50/app Residential:21+lots $1650+50/app Residential-extension $330 Final Approval[2] Residential $1320+$175/lot+$50/app Non-Residential $2000/lot+$50/app Final Approval Modification[2] Residential $330+$50/app Non-Residential $550+$50/app Final Approval Extension Residential $135 Non-Residential $330 Other: TOTAL *LOT/ACRE Post-Work Application Fee Add 50%App fee Lot Line Adjustment $350 Letter of Credit-modification or extension $440 Letter of Credit-collection up to 1%ofLoC Recreation Fee $2000/lotorunit land Disturbance $660+$55/acre SEQRA EIS Review(Draft&Final) TBD Legal Noticing if PB requires Public Hearing $50/app [1]Fees are based on per structure,except where noted. $0.00 TOTAL DUE [2]Legal ad required;includes City processing and publishing ForAdministrative Use Total Paid at Intake Revised Fee Balance Due JJ-Balance Paid Staff approval r° r SIJPE03MAROCETS July 22, 2021 To: The City of Rome,New York Pat Boni, Saxton Sign Corp. From: Thomas Lee,Price Chopper Design Project Manager The exterior building signage and pylon sign as shown in the attached drawing as produced by Saxton Signs is approved by Thomas Lee, Design Project Manager. On behalf of Price Chopper/Market 32,I hereby give Saxton Sign permission to obtain the signage permit. .409 Ihof Thomas Lee Design Project Manager STATE OF NEW YORK ) COUNTY OF SCHENECTADY ) SS.: On the 22"d day of July in the year 2021 before me, the undersigned a Notary Public in and for said state personally appeared Thomas Lee and personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he executed the same in his capacity, and that by his signature on the instrument, the individual executed the instrument. 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"1:: Z ...1 .., .ritta: Dias ,....--• '... 0 0 0, 5-,t), ..... .. ,,,,p, %FR _, 9 3 m >4 ,, ,,, g ,,,,,AA-4--4.,;.,-,16-e,,, ,44-4,,,,,,,,, 1,- ,,,, ,--, 31. -0 z -0 CA av tri 1:1) 0 --1 rc..„,-,'.,,-,,„,,,,,,,,,-4 ,-f•,,,,o,,,,1*,?,— , ,'020-, -,,,At-- 0 -240,,,-,-. i , 0k'-u• co . ,,--' C; (It za'u) pzjir-::-vt,Ifi7i,', kr)-$)4':I;-)31arl-;),,it.31hi .4 co0" c..1 cr. c...., twA l e• i c=ma• x AP • II G., NJ ',I "/".'N\ NYSI F 199 CHURCH STREET,NEW YORK,N.Y.10007-1100 New York State Insurance Fund I nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE AAAAAA 141670108 KEEVILY,SPERO-WHITELAW INC. 500 MAMARONECK AVENUE v HARRISON NY 10528 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER SAXTON CORPORATION OF ALBANY CITY OF SARATOGA SPRINGS 1320 RTE 9 474 BROADWAY CASTLETON NY 12033 SARATOGA SPRINGS NY 12866 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE G 813 625-1 934160 11/01/2021 TO 11/01/2022 09/21/2021 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 813 625-1, 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://WWW.NYSIF.COM/CERT/ CERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THE POLICY INCLUDES A WAIVER OF SUBROGATION ENDORSEMENT UNDER WHICH NYSIF AGREES TO WAIVE ITS RIGHT OF SUBROGATION TO BRING AN ACTION AGAINST THE CERTIFICATE HOLDER 70 RECOVER AMOUNTS WE PAID IN WORKERS'COMPENSATION AND/OR MEDICAL BENEFITS TO OR ON BEHALF OF AN EMPLOYEE OF OUR INSURED IN THE EVENT THAT, PRIOR TO THE DATE OF THE ACCIDENT, THE CERTIFICATE HOLDER HAS ENTERED INTO A WRITTEN CONTRACT WITH OUR INSURED THAT REQUIRES THAT SUCH RIGHT OF SUBROGATION BE WAIVED. 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 STATE INSURANCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 853819282 II I I III II I I)111(111111111(11111111111111111101111111111111 IMI 111111111 II I I��I I�IIII u 00000000000097012561 Form WC-CERT-NOPRINT Version 3(08/29/2019)[WC Policy-8136251] U-26.3 363 [00000000000097012561][0001-000008136251][$xG3[15725-29][Cert_NoP-CERT 1][01-00001] ----...*'".41, ® AC CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) `...-----' 12/16/2020 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 CONTACT NAME: Connie O'Brien Arthur J.Gallagher Risk Management Services, Inc. PHONE ESI:518-869-3535 FAX No):518-869-3580 30 Century Hill Drive Suite 200 ADDRESS: Connie OBrien@ajg.com Latham NY 12110 INSURER(S)AFFORDINGCOVERAGE NAIC# INSURER A:Selective Insurance Company of SC 19259 INSURED SAXTCOR-01 INSURER B:ShelterPoint Life Insurance Company 81434 Saxton Corporation of Albany 1320 Route 9 INSURER C: Castleton On Hudson, NY 12033 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1331705305 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. INSR ADDL SPOLICY EFF POLICY EXP TYPE OF INSURANCE NSD WVD POLICY NUMBER LIMITS (MM/DD/YYYY) (MM/DD/YYYY1 A X COMMERCIAL GENERAL LIABILITY S 2139450 1/1/2021 1/1/2022 EACH OCCURRENCE $1,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED — PREMISES(Ea occurrence) $500,000 MED EXP(Any one person) _ $15,000 _ PERSONAL&ADV INJURY _ $1,000,000 GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $3,000,000 POLICY X JECT LOC PRODUCTS-COMP/OP AGG 53,000,000 OTHER: $ A AUTOMOBILE LIABILITY S 2139450 1/1/2021 1/1/2022 COMBINED SINGLE LIMIT $1,000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) $ A X UMBRELLA LIAB X OCCUR S 2139450 1/1/2021 1/1/2022 EACH OCCURRENCE $5,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $5,000,000 DED X RETENTION$1njlnn $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE Ni A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ B Disability DBL-44433 1/1/2021 1/1/2022 A Leased&Rented S 2139450 1/1/2021 1/1/2022 $150,000 Installation Floater $100,000 $1,000 DED $1,000 DED DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Additional Insured Forms as required by written contract:CA 78 09NY 01 16,CG 7921 01 14 and CG 73 00 01 16. Sign erection,repair&manufacturing. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Saratoga Springs ACCORDANCE WITH THE POLICY PROVISIONS. 474 Broadway Saratoga Springs NY 12866 AUTHORIZED REPRESENTATIVE USA %/A'7/i Ct--/A -'', I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD STATE OF NEW YORK WORKERS'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 Carrier la. Legal Name and Address of Insured(Use street address only) lb.Business Telephone Number of Insured Saxton Corporation of Albany 518-732-7704 1320 Route 9 lc.NYS Unemployment Insurance Employer Registration Castleton On Hudson, NY 12033 Number of Insured ld.Federal Employer Identification Number of Insured or Social Security Number 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) ShelterPoint Life Insurance Company City of Saratoga Springs 474 Broadway 3b.Policy Number of entity listed in box"la": Saratoga Springs NY 12866 DBL-44433 3c. Policy effective period: 1/1/2021 to 1/1/2022 4.Policy covers: a.Ej 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 asdescribed above. Date Signed 12/16/2020 By (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number Title Regional Executive Vice President IMPORTANT: If box"4a"is 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"is checked,this certificate is NOT COMPLETE for purposes of Section 220,Subd.8 of the Disability Benefits Law. It must be mailed 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 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 Benefits Law with respect to all of his/her employees. Date Signed By (Signature of NYS Workers'Compensation Board Employee) Telephone Number Title Please Note: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-120.1. Insurance brokers are NOT authorized to issue this form. DB-120.1 (5-06)