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20191171 Lake Local Modification Explanation 3-5-20
The LA GROUP Landscape Architecture Engineering P.[_ Pevp(e.Purpose!.Place 40 Long Alley Saratoga Springs NY 12866 p:518-587-8100 f 518-587-0180 www.thelagroup.com MEMO TO: Mark Torpey, Chairman City of Saratoga Springs Planning Board FROM: Matt Brobston DATE: 3/4/2020 RE: 550 Union Avenue Administrative Action Request—Site Plan Amendment Additional information request At the request of the city planner this memo will provide explanation for the modifications to the site plan as a result of the DOT highway work permit process and modifications requested from that process. I will be providing to you the permit as submitted to the DOT from the traffic consultant as well as minutes from the meeting with DOT that directed the modifications to the plan. Unfortunately, no official comments were received from DOT but the meeting minutes were sent to them as a record of the events. The traffic consultant did not receive objections to the minutes. The following items are detailed in that memo and are paraphrased below. 1. The NYS DOT had said the proposed crosswalk and traffic calming measures would not be permitted and they requested they be removed from the project. The amendment set of plans indicates the removal of those items. 2. A revised driveway entrance to include an ADA compliant sidewalk would reduce the throat into the property below the DOT standards and it was decided to eliminate that sidewalk and striping. 3. The northern drive was determined by DOT to be eliminated in it entirety for safety and compliance reasons. It was decided it could not be removed by would be barricaded per NYS DOT requirements. This is indicated on the plans by bollards with a chain across the drive as requested by the DOT. 4. The vegetation within the DOT ROW would have to be low growing species and that was not the character requested by the board so those trees were removed from the ROW and included on-site as was discussed during the planning board meeting during approval. 5. The swale which was included within the ROW was to be moved onto the property and that was indicated to the DOT satisfaction on the revised plans. If there are questions that you may have please let me know and we can schedule a meeting to discuss or provide your comments and I can address them. Thank you for your consideration. Matthew C. Brobston, RLA Associate The LA GROUP Landscape Architecture and Engineering,P.C. People. Purpose. Place. 40 Long Alley Saratoga Springs,NY 12866 P:518/587-8100,x321 F:518/587-0180 mbrobston@thelagroup.com CC: G:\Proj-2015\201576 Lake Local\201576Submission Archive\2019-09-17 SP Modification\Admin Action Request.docx PHINNEY DESIGNGGUP October 2, 2019 Kristina L. Crowley, P.E. Regional Permit Engineer NYS Department of Transportation Region 1 50 Wolf Rd.—Suite 1s50 Albany, NY 12232 Reference: 550 Union Avenue Saratoga, NY 12 MEMORANDUM documenting our September 16, 2019 Meeting Dear Tina, Per our recent conversations via email and phone I wanted to document the discussions and proposed acceptable, NYSDOT compliant actions for our project site at 550 Union Ave. This memo will serve as our understanding about what will be required by NYSDOT in order to secure the PERM 33 permit for the project. Please review the following actions required by the NYSDOT for the PERM 33 approval: 1) The proposed crosswalk and associated traffic calming/mitigation measures will not be approved by the NYSDOT. As such we will not be including these measures in our project. 2) Providing an ADA compliant sidewalk at the southeastern driveway You indicated that you felt the Southern driveway to the site (nearest the bridge) would reduce the does not have enough throat width to below DOT standards (throat width would be less than 20'wide). accommodate an additional ADA compliant sidewalk along its edge along the existing guard rail. The existing We field measured the throat width of the driveway and it is approximately 24'wide. Based on the+s existing width, and in conjunction with No.1 above,we will eliminate the sidewalk and associated pavement striping so as not to neck down the throat any further. 3) After discussion regarding the Northernmost driveway along Union Avenue, you determined that NYSDOT would like to eliminate the driveway in its entirety for safety and compliance reasons. We indicated that the current property owners have deeded access to this roadway. Upon further discussion we will show the area of the road within the NYS DOT right-of-way to be "Removed or Barricaded per NYS DOT Requirements" 4) We discussed the planting of screening vegetation in the NYSDOT right-of-way. NYSDOT requires that an annual permit needs to be filed in order to add plantings in the right-of-way and that any planting would have to meet the NYSDOT specs. You indicated that the planting would be limited to low/no growth species. Due to these constraints,we will remove any plantings from the NYSDOT right-of-way. 5) You had mentioned that the rip rapexisting swale at the toe of the slope which was previously 518.587.7120 142 Grand Avenue I Saratoga Springs I NY 112866 phinneydesign.com 12180 . NY PHINNEY DESIGNGGUP installed in the right-of-way had been removed. We indicated that the swale would be reconstructedrip rap would be rc installcd as part of this project. Please refer to the attached plans indicating compliance with the aforementioned items. Based on this memo and in conjunction with the plans, we believe we have met your requirements for successful approval/issuance of the PERM 33 permit. Please feel free to reach out to me directly with any questions. Very Truly Yours, Phinney Design Group 6116-1L-- Edwin C. Anker IV, RA,AIA Troy Office Director I Senior Project Manager 518.587.7120 142 Grand Avenue I Saratoga Springs I NY 112866 phinneydesign.com 12180 . NY 1 Creighton September 24, 2019 Kristina L. Crowley, P.E. h AAanni n Regional Permit Engineer NYSDOT—Region 1 50 Wolf Road—Suite 1s50 Albany, NY 12232 RE: PERM 33—HWP Submission,550 Union Ave,City of Saratoga Springs, NY,Saratoga County, New York;CM Project No. 118-007 Dear Ms. Crowley, On behalf of the applicant,550 Union LLC,Creighton Manning(CM) is pleased to submit a hard copy and electronic copy of the PERM 33 Highway Work Permit application for the following work: • Modifications to the main driveway onto NYS Route 9P. Modifications include the extension of the existing sidewalk and curb (located on the west side of NYS Route 9P) along the south side of the main driveway. • The second driveway onto NYS Route 9P(to the north)will become an emergency access only driveway and will be signed and chained off, as such.The emergency access driveway opening width will remain the same. • Installation of a crosswalk across NYS Route 9P to the south side of the main driveway. • Drainage Structure and Culvert Installation across the emergency access driveway within the NYSDOT ROW. The culvert will outlet into an existing swale within the NYSDOT ROW. • Re-establishment/re-grading of an existing swale within the NYSDOT ROW. • Tree Plantings within the NYSDOT ROW. The following is attached to this letter for your consideration: • Site Plans & Details (L-01, L-02, L-07, L-08& L-12), Drainage Plans/Details (L-03 & L-11), Landscaping Plans/Details (L-05 & L-09) and Work Zone Traffic Control Details (L-13). • ACORD 25 and ACORD 855 Insurance certificates • PERM 36—Consultant Inspection Agreement • Contractors Proof of Workers Compensation Insurance & Disability Benefits Coverage The permit fee check and original copy of the Surety Bond will be forthcoming,once any comments regarding this submission are received. Please review the enclosed and provide comments as soon as possible. If you have any questions or require any additional information, please feel free to contact me. Respectfully, Creighton Manning Engineering, LLP Daniel P. Reynolds, P.E. Project Manager Cc (via email): 550 Union LLC—Applicant Trinity BCM—Co-Applicant LA Group—Site Engineer Enclosures Creighton Manning Engineering, LLP 2 Winners Circle I Albany, NY 12205 518.446.0396 www.cmellp.com �.....41 TRINI-2 OP ID: MB ACORO CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 41i...------ 09/09/2019 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 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 DeSanctis Insurance Agcy,Inc. PHONE FAX 100 Unicorn Park Drive (NC,No,Ext):781-935-8480 (NC,No): 781-933-5645 Woburn,MA 01801 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:The Charter Oak Fire Ins Co. 25615 INSURED Trinity Building and INSURER B:The Travelers Indemnity Co. 25658 Construction Management Corp. INSURER C:Travelers Indemnity Co of CT 25682 One Jewel Drive,Suite 322 Wilmington, MA 01887 INSURER D:Travelers Property Casualty Co 25674 INSURERE:North River Insurance Company 21105 INSURER F:Columbia Casualty Company 31127 COVERAGES CERTIFICATE NUMBER: 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE X OCCUR DTCO7H490909COF18 11/30/2018 11/30/2019 DAMAGE TO RENTED 300 000 PREMISES(Ea occurrence) $ A X XCU Included 11/30/2018 11/30/2019 MED EXP(Any one person) $ 5,000 F X POLLUTION C604114783($1M/$2M) 11/30/2018 11/30/2019 PERSONAL&ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 POLICY X 'ECT LOC PRODUCTS-COMP/OP AGG $ 4,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1 000 000 (Ea accident) s s B X ANY AUTO BA7H494331 11/30/2018 11/30/2019 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Per accident) X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 D EXCESS LIAB CLAIMS-MADE CUP4K0061151826 11/30/2018 11/30/2019 AGGREGATE $ 5,000,000 DED X RETENTION$ 10,000 $ WORKERS COMPENSATION X MUTE EMPLOYERS'LIABILITY STATUTE ER C ANY PROPRIETOR/PARTNER/EXECUTIVE YN NIA UB8J077203 MA,ME,IA,CT,NJ 11/30/2018 11/30/2019 E.L.EACH ACCIDENT $ 1,000,000 OFFIC(MandaR/MEn BER EXCLUDED? NV,NY,FL,PA,TX,MD,DC,RI" E.L.DISEASE-EA EMPLOYEE $ 1,000,000 (Mandatory in NH) If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 E Excess Umbrella 5228052417 11/30/2018 11/30/2019 XS UMB $19M$19M ADDITIONAL INSURED AND WAIVER OF SUBROGATION DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) "ADDITIONAL INSUREDS LIMITS ARE NO GREATER THAN THOSE REQUIRED BY WRITTEN CONTRACT"Other WC States:VA,AZ,CA,TN,AL,UT. RE: Surcharge/Erosion Sediment Control for the Lake Local Project. Phinney Design Group, 550 Union LLC& NYSDOT are Additional Insureds on a Primary& Non-Contributory basis on all policies except WC.A Waiver of Subrogation in favor of the Additional CERTIFICATE HOLDER CANCELLATION 550UN-1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 550 Union LLC THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 142 Grand Ave. Saratoga Springs, NY 12866 AUTHORIZED REPRESENTATIVE �°-�� ©(1.988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD HOLDER CODE 550UN-1 TRINI-2 PAGE 2 NOTEPAD. INSURED'S NAME Trinity Building and OP ID: MB Date 09/09/2019 Insureds applies on all policies. AGENCY CUSTOMER ID:TRINI-2 OP ID: MB NEW YORK CONSTRUCTION ACOR'O DATE Y) CERTIFICATE OF LIABILITY INSURANCE ADDENDUM 09/09/2019 THIS ADDENDUM SUMMARIZES SOME OF THE POLICY PROVISIONS IN THE REFERENCED INSURANCE POLICIES AND IS ISSUED AS A MATTER OF INFORMATION ONLY; IT CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. ALL TERMS, EXCLUSIONS AND CONDITIONS IN THE ACTUAL POLICY SHOULD BE CONSULTED FOR A MORE DETAILED ANALYSIS OF COVERAGE, AS THIS ADDENDUM DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES. AGENCY NAMED INSURED(S) DeSanctis Insurance Agcy, Inc. Trinity Building and POLICY NUMBER EFFECTIVE DATE CARRIER NAIC CODE DTC07H490909C0F18 11/30/2018 The Charter Oak Fire Ins Co. 25615 ADDENDUM INFORMATION CERTIFICATE NUMBER: REVISION NUMBER: A. Insurer X Admitted/authorized Excess line or free trade zone B. General Liability(GL)policy form X ISO/ISO modified Other C. Specific operations excluded or restricted(GL policy) Location: Type of construction: Building height: Classifications [see attached declarations/endorsement] Designated work [see attached endorsement] D. Additional insured endorsement(GL policy) CG 2010 CG 2026 CG 2032 CG 2033 CG 2037 CG 2038 X Other: #: CGD2 46 Title: Blanket Additional Insured (Contractors) E. According to the terms of this GL policy,the additional insured has primary and noncontributory coverage X Yes No and no other option is available with this insurer F. Additional insured will receive advance notice if insurer cancels(GL policy) Yes X No and no other option is available with this insurer G. Blanket contractual liability located in the"insured contract"definition(Section V,Number 9,Item f.in the ISO CGL policy)is removed or restricted Yes and no other option is available with this insurer X No changes made H. "Insured contract"exception to the employers liability exclusion is removed or modified(GL policy) Yes and no other option is available with this insurer X No changes made I• GL policy(including endorsements)does not cover the additional insured for claims involving injury to employees of the named insured or subcontractors(not workers'compensation) Yes and no other option is available with this insurer X No changes made ACORD 855 NY(2014/05) Attach to ACORD 25 ©2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID:TRINI-2 OP ID: MB ADDENDUM INFORMATION (continued) J. Earth movement,excavation or explosion/collapse/underground property damage is excluded or restricted(GL policy) Yes and no other option is available with this insurer X No changes made K. Insured vs.insured suits(cross liability in the ISO CGL policy)are excluded or restricted(other than named insured vs.named insured) Yes and no other option is available with this insurer X No changes made L. Property damage to work performed by subcontractors(exception to the"damage to your work"exclusion in the ISO CGL policy)is excluded or restricted Yes and no other option is available with this insurer X No changes made M. Excess/umbrella policy is primary and non-contributory for additional insureds Yes, by specific policy provision Yes, by endorsement No and no other option is available with this insurer (1/(g,..A._c_... a , 6......„,„.9 ....A_____ 09/09/2019 AUTHORIZED REPRESENTATIVE SIGNATURE DATE(MM/DD/YYYY) ACORD 855 NY(2014/05) Page 2 of 2 AGENCY CUSTOMER ID:TRINI-2 OP ID: MB NEW YORK CONSTRUCTION ACOR'O DATE Y) CERTIFICATE OF LIABILITY INSURANCE ADDENDUM 09/09/2019 THIS ADDENDUM SUMMARIZES SOME OF THE POLICY PROVISIONS IN THE REFERENCED INSURANCE POLICIES AND IS ISSUED AS A MATTER OF INFORMATION ONLY; IT CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. ALL TERMS, EXCLUSIONS AND CONDITIONS IN THE ACTUAL POLICY SHOULD BE CONSULTED FOR A MORE DETAILED ANALYSIS OF COVERAGE, AS THIS ADDENDUM DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES. AGENCY NAMED INSURED(S) DeSanctis Insurance Agcy, Inc. Trinity Building and POLICY NUMBER EFFECTIVE DATE CARRIER NAIC CODE CUP4K0061151826 11/30/2018 Travelers Property Casualty Co 25674 ADDENDUM INFORMATION CERTIFICATE NUMBER: REVISION NUMBER: A. Insurer X Admitted/authorized Excess line or free trade zone B. General Liability(GL)policy form ISO/ISO modified Other C. Specific operations excluded or restricted(GL policy) Location: Type of construction: Building height: Classifications [see attached declarations/endorsement] Designated work [see attached endorsement] D. Additional insured endorsement(GL policy) CG 2010 CG 2026 CG 2032 CG 2033 CG 2037 CG 2038 Other: #: Title: E. According to the terms of this GL policy,the additional insured has primary and noncontributory coverage Yes No and no other option is available with this insurer F. Additional insured will receive advance notice if insurer cancels(GL policy) Yes No and no other option is available with this insurer G. Blanket contractual liability located in the"insured contract"definition(Section V,Number 9,Item f.in the ISO CGL policy)is removed or restricted Yes and no other option is available with this insurer No changes made H. "Insured contract"exception to the employers liability exclusion is removed or modified(GL policy) Yes and no other option is available with this insurer No changes made I• GL policy(including endorsements)does not cover the additional insured for claims involving injury to employees of the named insured or subcontractors(not workers'compensation) Yes and no other option is available with this insurer No changes made ACORD 855 NY(2014/05) Attach to ACORD 25 ©2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID:TRINI-2 OP ID: MB ADDENDUM INFORMATION (continued) J. Earth movement,excavation or explosion/collapse/underground property damage is excluded or restricted(GL policy) Yes and no other option is available with this insurer No changes made K. Insured vs.insured suits(cross liability in the ISO CGL policy)are excluded or restricted(other than named insured vs.named insured) Yes and no other option is available with this insurer No changes made L• Property damage to work performed by subcontractors(exception to the"damage to your work"exclusion in the ISO CGL policy)is excluded or restricted Yes and no other option is available with this insurer No changes made M. Excess/umbrella policy is primary and non-contributory for additional insureds X Yes, by specific policy provision Yes, by endorsement No and no other option is available with this insurer 09/09/2019 AUTHORIZED REPRESENTATIVE SIGNATURE DATE(MM/DD/YYYY) ACORD 855 NY(2014/05) Page 2 of 2 TATEOFE0YORK Department of OPPORTUNITY Transportation Form PERM 33 (July 2015) Highway Work Permit Application for Non-Utility Work Instructions and Form (For Commercial Driveways, use Form PERM 33-COM) INSTRUCTIONS FOR COMPLETING THE APPLICATION FRONT OF APPLICATION Three (3)copies of the entire application, work plans and all other supporting documents must be submitted. At the time of application, certain information relative to fees and deposits may be contingent upon determinations to be made by the Department. In such cases, the information may be left blank and remittance withheld until a determination is made. Please complete the following: • Permittee name, address, phone and email address. Provide joint applicant contact information, if appropriate. If there are additional applicants, attach contact information on a separate sheet. • Name and phone number(s)of emergency contact person. • If permit is to be returned to someone other than the applicant, complete this section. • If the guarantee deposit or bond is to be returned to someone other than applicant, complete this section. • Estimate the cost of work being performed in the state highway right-of-way and provide this figure. • Indicate anticipated duration of work to be performed with starting date and ending date. • Indicate the form of insurance coverage to be provided. • Give a brief description of the work that is proposed to be done under this permit. • Indicate whether any overhead and/or underground work(5 foot or greater depth) is included in the proposed work. • Plans and specifications should accompany this application for any work that involves construction within the state highway right-of-way. Place a check mark on the lines for plans and specifications if they are attached to this application. • Location of the project should be identified by State Route, highway reference marker(s), and the municipality and county in which work area is located. • In regard to State Environmental Quality Review(SEQR), indicate the type of action, the name of the Lead Agency, and what date the final determination was made, if available. • Signature of applicant and date. • Signature of second applicant, if any, and date. BACK OF APPLICATION • Check type of work that will be performed. • In the appropriate column, indicate total amount of permit fees (Include insurance fee for residential work) • Indicate type of performance security provided (bond, deposit, letter of credit), if required. • Indicate check number of deposit or bond number. RESPONSIBILITIES OF PERMITTEE PURSUANT TO NON-UTILITY HIGHWAY WORK PERMITS NOTE: FAILURE TO OBTAIN A PERMIT OR FAILURE TO COMPLY WITH THE TERMS OF A PERMIT MAY RESULT IN THE DEPARTMENT HALTING THE ACTIVITY FOR WHICH A PERMIT IS REQUIRED UNTIL ADEQUATE CORRECTIONS HAVE BEEN MADE. 1. LIMITATIONS ON USE: The specific site identified in this Highway Work Permit, and only that site identified, will be available for use by Permittee only for the purpose stated in this Permit and only on the date(s)and for the duration designated in this permit.This Permit does not authorize any infringement of federal, state or local laws or regulations, is limited to the extent of the authority of NYSDOT and is transferable and assignable only with the written consent of the Commissioner of Transportation. The Commissioner reserves the right to modify fees and to revoke or annul the Permit at any time, at his/her discretion without a hearing or the necessity of showing cause. 2. CONDITIONS OF USE: NYSDOT makes no affirmation that the state-owned site used for the work has been designed, constructed, or maintained for the purpose of the conduct of the work. The Permittee assumes full responsibility for planning and conducting a safe and orderly project that does not expose workers or the public to any unreasonable hazards and that involves a minimal disruption of the normal uses of the state and local highway systems. It shall be the sole obligation of the Permittee to determine whether the site is suitable for the purpose of safely conducting the work. The Permittee assumes all responsibility for assuring that the use of the highway/property conforms to applicable requirements of law, including, but not limited to those set forth herein. Permittee agrees to assure compliance with New York Labor Law, industrial regulations,and OSHA regulations, and to assure the safety of all workers who will be engaged to do the permitted work. 3. INSURANCE COVERAGE: Permittee must have the insurance that is required for the type and extent of the work being performed. Permittee agrees to maintain liability insurance in full force and effect throughout the term of the highway work permit. Expiration of,or lack of, liability insurance automatically terminates the permit. To comply with this requirement, an applicant must furnish the Department with one of the following: • A completed Certificate of Insurance evidencing the required types and limits of insurance coverage,with New York State Department of Transportation named as an additional insured on the commercial general liability policy. An industry standard ACORD 25 form with an ACORD 855 Addendum is acceptable evidence of the required coverage. Certificate Holder should be indicated as New York State Department of Transportation,with the address of the issuing office. • A fully executed Undertaking Agreement may be provided by Municipalities, Public Utilities, Transportation Corporations, Public Service Corporations or Railroads,as an alternative to providing proof of commercial general liability the insurance. • Homeowners applying for a residential work permit(driveways, improvements or tree work)and performing their own work have the option to pay a$25 Insurance Fee,and waive the requirement to provide insurance coverage. Any contractor doing work on the homeowner's behalf must be listed on the permit and provide satisfactory proof of insurance as set forth below. See"PERM 33 Submission Package Requirements"on page 4 for more detailed guidance on insurance coverage. 4. COMPENSATION AND DISABILITY INSURANCE COVERAGE: Permittee is required to have compensation insurance and disability coverage as noted in the provisions of the Worker's Compensation Law and Acts amendatory thereof for the entire period of the permit, or the permit will be invalid. Applicant must provide proof of coverage(Form C-105.2, U-26.3 or SI-12 for Worker's Compensation, and DB-120.1 or DB-155 for Disability Benefits), or provide proof of exemption from this requirement(Form CE-200). 5. INDEMNIFICATION: Permittee agrees that, in addition to any protection afforded to NYSDOT under any available insurance, NYSDOT shall not be liable for any damage or injury to the Permittee, its agents, employees, or to any other person, or to any property, occurring on the site or in any way associated with Permittee's activities or operations;whether undertaken by Permittee's own forces or by contractor or other agents working on Permittee's behalf. To the fullest extent permitted by law, the Permittee agrees to defend, indemnify and hold harmless the State of New York, NYSDOT and their agents from and against all claims, damages, losses and expenses, including but not limited to attorneys'fees,arising out of any claim, including but not limited to claims for personal injuries, property damage or wrongful death and/or environmental claims, in any way associated with the Permittee's activities or operations, no matter how caused. 6. NOTIFICATION: The following should be notified at the appropriate time as shown below: • Commissioner of Transportation, through the NYSDOT regional office,one week prior to commencing work. • Area gas distributors, 72 hours prior to any blasting. • Utility companies with facilities in work areas, before starting work(in accordance with Industrial Code 53). • Permission from utility company must be obtained before commencing work affecting the utilities'facilities. • NYSDOT regional signal maintenance shop, 3 days prior to starting work(traffic signal work). • NYSDOT regional office, at conclusion of work, and return original copy of permit to Resident Engineer. NOTIFICATION FOR ANNUAL PERMITS: Notify by phone,the Regional or Resident Engineer's Office, one week in advance, each time regular maintenance work is to be performed. In emergencies, notification by phone,fax or email should be made as soon as is practical, no later than the next business day. 7. SITE CARE AND RESTORATION: A bond, deposit(bank cashier's check), or a Letter of Credit, in an amount designated by the Department of Transportation, may be required before a permit is issued, in order to guarantee restoration of the site to its original condition. A fully executed Undertaking Agreement may be accepted as an alternative security, where applicable. If the Department is obliged to restore the site to its original condition,the costs to the Department will be deducted from the amount of the permittee's deposit at the conclusion of the work. Costs in excess of the bond/deposit on file will be billed directly to the permittee. If permittee posts a Letter of Credit, the Department may elect to have a contractor restore the site, and issue a draft drawn against the Letter of Credit as payment. • Anyone working within state highway right-of-way must wear high visibility apparel and hard hat meeting ANSI Class 2 requirements. • No unnecessary obstruction is to be left on the pavement or the state highway right-of-way, or in such a position as to block warning signs during non-working hours. • No work shall be done to obstruct drainage or divert creeks,water courses or sluices onto the state highway right-of-way. • All false work must be removed and all excavations must be filled in and restored to the satisfaction of the Regional Maintenance Engineer. 8. COSTS INCURRED BY ISSUANCE OF THIS PERMIT: All costs beyond the limits of any liability insurance,surety deposits, etc.are the responsibility of the permittee.The State shall be held free of any costs incurred by the issuance of this permit, direct or indirect. 9. SUBMITTING WORK PLANS: The applicant will submit three (3)copies of work plans and/or maps as required by the Department. This shall include (but not limited to)such details as: measurements of driveways with relation to nearest property corner; location of existing and proposed poles, guide rail,signal equipment,trees or drainage structures; positions of guys supporting poles; a schedule of the number of poles and feet of excavation necessary for completion of work on the State right-of-way. A description of the proposed method of construction will be included. • Plan work with future adjustments in mind, as any relocation, replacement or removal of the installation authorized by this permit and made necessary by future highway maintenance, reconstruction or new construction,will be the responsibility of the permittee. • Driveway plans should be prepared in accordance with NYSDOT POLICY AND STANDARDS FOR ENTRANCES TO STATE HIGHWAYS. • The permittee must coordinate the work with any State construction being conducted. 10. TRAFFIC MAINTENANCE: A plan detailing how the permittee intends to maintain and protect traffic shall be submitted with work plans. Traffic shall be maintained on the highway in a safe manner during working and non-working hours until construction is completed. The permittee is responsible for traffic protection and maintenance, including adequate use of signs, barriers, and flag persons during working and non-working hours until construction is completed. All sketches will be stamped with"MAINTENANCE OF TRAFFIC SHALL BE IN CONFORMANCE WITH THE NATIONAL MANUAL ON UNIFORM TRAFFIC CONTROL DEVICES." 11. COST OF INSPECTION AND SUPERVISION: Prior to issuance of the Highway Work Permit,the permittee may be required to sign an INSPECTION PAYMENT AGREEMENT FOR HIGHWAY WORK PERMITS (FORM PERM 50)agreeing to the payment of construction inspection charges, based on the number of work days involved. In certain cases, the permittee may also be required to sign a PAYMENT AGREEMENT FOR HIGHWAY WORK PERMITS DESIGN REVIEW (FORM PERM 51)agreeing to design review charges, based on the number of work hours in which Department employees were engaged in design review activity. 12. SCOPE: • Areas Covered: Permits issued are for highways, bridges and culverts over which the New York State Department of Transportation has jurisdiction. (Local governments issue permits for highways under their jurisdiction.) Work locations must be approved by the Department. • Maintenance: Unless noted otherwise, applicant shall be fully responsible for the maintenance of all items installed and/or altered as shown on the approved permit plans and documents. Property owners having access to a state highway shall be fully responsible for the maintenance of their driveway in accordance with POLICY AND STANDARDS FOR ENTRANCES TO STATE HIGHWAYS. • Work Commencement: The Permittee shall have a copy of the permit available at the site during the construction period.Work should start within 30 days from validation date of permit or said permit may be revoked. 13. REPORTING ACCIDENTS: Permittee is required to report any accidents that occur during the course of the permit work to their insurance company, and to provide the Department with a copy of any such report. 14. COMPLETION OF PROJECT: Upon completion of the work within the State highway right-of-way authorized by the work permit, the person and his or its successors in interest shall be responsible for the maintenance and repair of such work or portion of such work as set forth within the Terms and Conditions of the Highway Work Permit. PERM 33 Submission Package Requirements Submit three (3) copies of the final submission package: Submission package must include the entire PERM 33 with all work plans and supporting documents, including the following (check all that apply): nStamped Final Plans—Submit in PDF file format on CD, with three (3) paper copies (1" = 50'), or as requested nACORD 25- Certificate of Insurance, with NYSDOT named as Additional Insured (See line 3 below). n ACORD 855- New York Construction Certificate of Liability Insurance Addendum (See line 3 below). piPERM 1, 2, 6 or 16- Undertaking Agreement, if applicable (See line 4 below). nPERM 36-Attachment to Highway Work Permit—Consultant Inspection, if applicable nPERM 44-Surety Bond— Performance bond in Applicant's name, or deposit (Bank cashier's check required) nPERM 50—Inspection/Supervision Payment Agreement, if applicable nProof of Worker's Compensation Insurance (Form C-105.2, U-26.3 or SI-12), or proof of exemption (Form CE-200) nProof of Disability Benefits Coverage (Form DB-120.1 or DB-155), or proof of exemption (Form CE-200) nPermit Fee (Include $25 Insurance Fee for residential operations) n Other(specify): Insurance Requirements 1) In most cases, Permittee must provide proof of Commercial General Liability insurance coverage with limits of liability not less than $1,000,000 per claim/occurrence, unless any of the following circumstances exist, in which case the limits of liability shall not be less than $5,000,000 per claim/occurrence: (a) The estimated value of permitted work in state right-of-way is$250,000 or more (see line 6 below); (b) The permitted work requires or includes the construction, alteration or maintenance of underground features at any depth five feet or more below grade; (c) The permitted work requires or includes the construction, alteration or maintenance of overhead features that include, but are not limited to, traffic signals, overhead sign structures, retaining walls or other grade separation structures. 2) Exceptions to the above liability limits include: (a) Annual maintenance permits require limits of liability not less than $5,000,000 per claim/occurrence; (b) Permits for vegetation control activities require limits of liability not less than $1,000,000 per claim/occurrence; (c) Residential driveway permits require limits of liability not less than $500,000 per claim/occurrence; and (d) Adopt-a-Highway permits are exempt. 3) ACORD 25 with ACORD 855 (New York Construction Addendum)shall be submitted as an acceptable proof of liability coverage. New York State Department of Transportation should be named as Additional Insured and as the Certificate Holder at the address of the issuing office. 4) Municipalities, public utilities, public authorities and railroads may elect to provide a fully executed Undertaking Agreement as a substitute for providing proof of insurance coverage, or any other financial security otherwise required. 5) Homeowners may pay a$25 Insurance Fee in lieu of providing proof of insurance, however any contractor performing on behalf of a homeowner and who is named on the permit must provide proof of insurance as outlined above. 6) When the estimated cost of work being performed in the right-of-way equals or exceeds $250,000, Permittee must additionally provide proof of a Protective Liability(OCP) insurance policy with a minimum liability limit of$1,000,000 per occurrence, with New York State Department of Transportation as Named Insured. Permittee agrees to maintain liability insurance in full force and effect throughout the term of the highway work permit. Expiration of,or lack of, liability insurance coverage automatically terminates the permit. For more information on insurance requirements, go to: www.dot.ny.gov/permits-insurance PERM 33 NON-UTILITY(7/15) SUBMIT THREE(3)COPIES STATE OF NEW YORK DEPARTMENT OF TRANSPORTATION HIGHWAY WORK PERMIT APPLICATION FOR NON-UTILITY WORK Application is hereby made for a highway work permit: For Joint application, name and address of Applicant 2 below: Name 550 Union LLC Name Trinity Building + Construction Mgmt. Corp Address 142 Grand Avenue Address 621 Columbia Street City Saratoga Springs State NY Zip 12866 City Cohoes State NY Zip 12047 Applicant Phone(518)587-7120 Applicant 2 Phone(978)267-3670 Applicant Email Address mphinney@phinneydesign.com Applicant 2 Email Address mrusso@trinitybcm.com Emergency Contact Mike Russo - Sr. Project Manager Emergency Phone (518 ) 441-0828 RETURN PERMIT TO: (if different from Permittee) RETURN DEPOSIT/BOND TO: (if different from Permittee) Name Name Address Address City State Zip City State Zip DESCRIPTION OF PROPOSED WORK: Driveway Modifications to existing commercial driveway, Catch basin and culvert installation, Site Grading & re-establishment of swale within NYSDOT ROW, Tree Plantings within NYSDOT ROW.(See attached plans and details). Estimated cost of work being performed in highway right-of-way: $ 35,000 Anticipated duration of work: From 10/1/19 to 6/30/19 (applies to the operations indicated on the reverse side) WILL OVERHEAD OR UNDERGROUND(5'+)OPERATIONS BE INVOLVED IN THE PROPOSED WORK? YES IN NO L ATTACHED: Plans n Specifications n LOCATION: State Route: 9P Located Between Reference Markers 15011083 and 15011085 City/TownNillage of Saratoga Springs County of Saratoga SEQR REVIEW(select one) []Type II[]Type I[]Unlisted LEAD AGENCY: Saratoga Springs Planning Board DATE OF DETERMINATION: 6/7/1 8 Insurance(check one): n General Liability Insurance n Undertaking _0_Insurance Fee(residential operations only) NOTE: PERMIT IS ISSUED CONTINGENT UPON ALL LOCAL REQUIREMENTS BEING SATISFIED ACKNOWLEDGMENT: ON BEHALF OF THE APPLICANT,I HEREBY REQUEST A HIGHWAY WORK PERMIT,AND DO ACKNOWLEDGE AND AGREE TO THE RESPONSIBILITIES OF PERMITTEE AND THE OTHER OBLIGATIONS SET FORTH IN THIS PERMIT AND WARRANT COMPLIANCE THEREWITH. Applicant Signature_ I + _ Date 9/23/19 Applicant 2 Signature }'1`'`" Date 9/23/19 Approval recommended by Resident Engineer Res No Date Approved by Regional Traffic Engineer Reg No Date Operational Type and Description Permit Insurance Total Fees Fee Fee $ 0.00 DRIVEWAYS 5a1 Residential Driveway(includes field entrances) I 15 I 25 5a6 Temporary access road or street 200 P rY For Commercial Driveways and subdivisions streets, use form PERM 33-COM IMPROVEMENTS 5b1 Residential I 15 25 l/ 5b2a Commercial-Sidewalk, curb paving, drainage,etc. 41 200 �� 4/ 5b2b Commercial—Grade,seed, improve land contour,clear brush 100 / l/ 5b2c Commercial—Resurface existing road or driveway 50 ii 5b2d1 Annual resurfacing of roadways and driveways—PER COUNTY 150 0 Number of counties: oil, Ai 5b2d2 Annual resurfacing of roadways and driveways—PER REGION 400 '� TREE WORK 125 5c1 Residential 15 25 l/ 5c2a Commercial removal or planting 5c2b Commercial pruning,applying chemicals to stumps 25 ;� 5c3 Vegetation control for advertising signs—PER SIGN 150 #' Number of Signs: MISCELLANEOUS CONSTRUCTION AND WORK OPERATIONS 5d1 Beautify ROW(civic groups only) NIC % 5d2a Temporary signs, banners,decor(not-for-profit organizations) NIC 5d2b Temporary signs, banners,decor(other organizations) 25 5d3 Traffic control signals 500 � 4 5d4 Warning and entrance signs 25 5d5 Miscellaneous—Requiring substantial review(describe below) 400 • 5d6 Miscellaneous (describe below) 25 d OTHER TYPES OF HIGHWAY WORK PERMITS 6 Encroachment caused by DOT acquisition of property 25 pry A. 7a1 Compulsory permit required for demolition requested by DOT N/C %VO4 7a2 Compulsory permit required for moving requested by DOT N/C or 7b Improvement to meet Department standards N/C ol � 8 Miscellaneous (describe below) 25 or 9 Adopt-a-Highway (exempt from insurance requirement) N/C d .14 Description of Miscellaneous Operation: PERFORMANCE SECURITY(Select one): Guarantee Deposit-Cash l❑ Performance Bond lE Letter of Credit I❑ Guarantee Deposit Amount: Guarantee Deposit Check Number or Bond Number (To be completed by NYSDOT issuing office) Project Identification Number Highway Work Permit No. State Highway(SH)Number Record ID Number PERM 33(7/15)REVERSE PERM 36(Rev. 04/15) ATTACHMENT TO HIGHWAY WORK PERMIT—CONSULTANT INSPECTION AGREEMENT This is an attachment to Highway Work Permit No. issued to 550 Union, LLC (Permittee)pursuant to Section 52 of the Highway Law for work on State Highway right-of-way. This attachment, the application submitted by the Permittee, and all plans and other documents submitted as part of the application or subsequently approved by the New York State Department of Transportation(NYSDOT)are a part of and are incorporated into the Permit described above. The Permittee agrees to the following conditions,requirements,and obligations which are in addition to,not in lieu of,any requirements contained in Title 17 of the New York Code of Rules and Regulations(NYCRR),Parts 125-130 and/or any requirements stated in the application submitted by the Permittee. 1.All work on State Highway right-of-way shall be according to plans and specifications entitled Lake Local Site Plan prepared by The LA Group and dated 8/21/19 ,which plans and specifications were approved by NYSDOT on ,and are attached to and are made part of this permit as Schedule A (Plans). No modifications will be made to the Plans without the express written permission of NYSDOT. It is understood that alterations to the plans may be necessary to meet unforeseen field conditions or to provide for inadvertent errors or omissions. These alterations will be made by the Permittee,with the approval of and to the satisfaction of NYSDOT. The intent of this requirement is not to alter the scope of the work as approved by NYSDOT,but to provide flexibility to make alterations,additions,and subtractions necessary to complete the work within the original intent and scope of the Plans. 2.Permittee agrees that,in addition to any protection afforded to NYSDOT under any available insurance,NYSDOT shall not be liable for any damage or injury to the Permittee,its agents,employees,or to any other person,or to any property,occurring on the site or in any way associated with Permittee's activities or operations;whether undertaken by Permittee's own forces or by contractor or other agents working on Permittee's behalf.To the fullest extent permitted by law,the Permittee agrees to defend,indemnify and hold harmless the State of New York,NYSDOT and all employees or officers of the State and their agents from and against all claims,damages,losses and expenses,including but not limited to attorneys' fees,arising out of any claim,including but not limited to claims for personal injuries,property damage or wrongful death and/or environmental claims,in any way associated with the Permittee's activities or operations,no matter how caused. 3.All authority granted by this Permit relates solely to that authority within the discretion of the Commissioner of Transportation.All other permits and approvals required for the project shall be the responsibility of the Permittee.There shall be no liability or obligation placed upon NYSDOT with respect to such other requirements. 4.This Permit shall not be construed as conveying to the Permittee or to any other person,the right to enter upon or trespass upon the lands of parties not party to this agreement for any purpose,nor shall this Permit be construed as authorizing the impairment of any rights,title,or interest in real or personal property held or vested in a person not a party to this agreement. 5.In the event that Permittee fails to comply with the terms of the Permit,NYSDOT has the right to cancel this approval at any time.NYSDOT may decide to continue,rescind,or modify this Permit in such a manner as it finds just and equitable. 6. The Permittee shall retain,at its own cost,the services of a reputable engineering firm("Consultant"),to inspect and monitor the work performed under the Permit.The Consultant shall monitor the work of the Permittee and the Permittee's Contractors to ensure that the work performed under the permit is done in accordance with the plans,the Standard Specifications,and all other requirements of the permit.As necessary,the Consultant will inform,orally and in writing,the Permittee and NYSDOT of deficiencies in workmanship,material quality,Work Zone Traffic Control,Safety,etc. Failure of the Permittee to properly respond to a notice of deficiency shall be deemed a breach of the Permit and shall be grounds for denial of NYSDOT's approval of the entire work or portions of the work under the permit. Inspection of the work by the Consultant shall not relieve the Permittee of responsibility for compliance with all of the conditions of the permit. The engineering firm(Consultant)and its inspector(s)retained by the Permittee shall be approved in writing by NYSDOT prior to the start of the work. The firm shall be registered to practice professional engineering in New York State, and experienced in inspection of highway, structural, utility,and traffic signal work,in accordance with the scope of the work to be performed under the permit. The primary inspector shall be certified at NICET Level II or above,or the equivalent. No work shall be performed under this permit before the Consultant and its inspector(s) have been approved by NYSDOT, and has assigned sufficient staff to the project to carry out the necessary project duties as described below.If NYSDOT determines that the personnel assigned to this work are insufficient, the Permittee shall promptly make arrangements to provide sufficient personnel. If the Permittee fails to make such arrangements within a reasonable time,NYSDOT may order the project shut down until sufficient personnel are provided.NYSDOT shall have the right to approve or reject the individual employees to be assigned to inspection of the work authorized by the Permit before their employment on the project. 7.The services to be performed by the Consultant shall include but shall not be limited to the following: A. Construction inspection in accordance with the standard practices of NYSDOT. The Consultant is to certify that each item of work conforms to the Plans. B.Maintenance of records in accordance with the current NYSDOT Manual of Uniform RecordKeeping on Highway Contracts.For more information,refer to https://www.dot.ny.gov/main/business-center/contractors/construction-division/forms-manuals-computer-applications- general-information PERM 36(Rev. 04/15) ATTACHMENT TO HIGHWAY WORK PERMIT—CONSULTANT INSPECTION AGREEMENT—Page 2 C. Obtaining all necessary material samples and conducting all necessary material tests in accordance with NYSDOT's Materials methods. If NYSDOT determines that plant inspections for hot mix asphalt and portland cement concrete will be required,the Permittee shall make arrangements with a testing laboratory approved by NYSDOT to perform such inspections according to NYSDOT's Standards. The Permittee will be responsible for all costs associated with obtaining and testing of samples. D.Preparation of all drawings,sketches,and plans necessary for changes to meet actual field conditions. E.Providing three sets of Record(As-Built)Plans upon completion of the work. F. Reviewing and inspecting compliance with all aspects of the Work Zone Traffic Control provisions of the Plans,the Permit,MUTCD and NYSDOT Standard Specifications and notifying NYSDOT of any noncompliance issues. G. The Consultant shall notify NYSDOT,Permittee and Contractor of a circumstance or condition of the work observed by and known to the Consultant per required training to be a violation of a Federal, State or local law,ordinance or regulation. The Consultant shall inform NYSDOT of any violations in the performance of the work on this permit which are not immediately corrected.In the event the Consultant recognizes a Contractor's oversight or a Contractor's disregard of project safety requirements which poses an immediate risk of serious personal injury and/or property damage, the Consultant shall have the authority to immediately issue a Stop-Work Order, and then the Consultant shall promptly notify NYSDOT and the Permittee of such order. Notification and/or issuance of a Stop-Work Order by the Consultant shall not relieve the Contractor from sole responsibility for job site safety and compliance with all applicable Federal,State or local laws,ordinances and regulations. NYSDOT reserves the right to inspect the work,but is under no obligation to perform such inspections and assumes no responsibility for lack of any compliance on the part of the Contractor. If NYSDOT determines that there are serious or persistent violations of applicable Federal,State or local laws,ordinances and regulations in the work of this Permit,NYSDOT may issue a Stop-Work Order and all Permit work will cease immediately. In addition,the Permit may be revoked if the safety issues are not resolved to NYSDOT's satisfaction. The Consultant is responsible for monitoring the Contractor's efforts to maintain traffic and protect the public from damage to person or property in accordance with plans and specifications,within the limits of,and for the duration of,the permit work. 8. The Permittee shall reimburse the State for all reasonable Permit engineering review costs, and for any NYSDOT completed inspections which may be necessary due to negligence on the part of the Permittee,its Contractors,or the Consultant. These costs shall include,but not be limited to, salaries and fringe benefits for NYSDOT staff performing inspections, and for material inspectors, travel costs, etc. All work performed by the Permittee shall be at no cost to the State. If costs are incurred by NYSDOT,NYSDOT will bill the Permittee monthly,and the Permittee agrees to pay all such bills within 30 calendar days of the billing date.Failure to pay such bills promptly shall be deemed a breach of the Permit. 9.Prior to the intended commencement of work,the Permittee shall develop a schedule from the contractors'work programs for the accomplishment of all work authorized by the Permit and shall submit this schedule to the Consultant and NYSDOT for informational purposes. The Permittee shall promptly notify the Consultant and NYSDOT of any changes to the schedule. 10. The Permittee shall designate in writing to NYSDOT the Contractor's on-site person who will be responsible for all construction activities covered by this Permit,and shall immediately notify the Consultant and NYSDOT in writing if there is any change of the person so designated. The Permittee shall also designate one or more persons as emergency contacts and shall establish an emergency telephone list. This list shall be kept current by the Permittee and shall be provided to the Consultant,to NYSDOT,and to local public safety agencies. 11.Prior to the commencement of work the Permittee shall arrange a pre-construction meeting with NYSDOT staff,the Consultant,the Permittee, and the Permittee's contractors. The purpose of this meeting is to ensure that there is a clear understanding,especially on the part of the Contractors and Consultant,of the requirements imposed by the terms and conditions of the Permit. The Permittee shall notify the Regional Permit Engineer a minimum of 10 days prior to the meeting date. pe i."--k1;144 .12-ttILUAW Consultant Authorized Signature * Permittee Signature Associate Principal Michael R. Phinney, Partner Title Title The LA Group 550 Union, LLC Consulting Firm Corporation *Consultant authorized signature must be by person who can legally commit the consulting firm to the requirements of this agreement. YORK Workers= CERTIFICATE OF STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board la.Legal Name&Address of Insured(use street address only) lb.Business Telephone Number of Insured Trinity Building and Construction Management Corp. 781-938-0008 One Jewel Drive,Suite 322 Wilmington,MA 01887 1c.NYS Unemployment Insurance Employer Registration Number of Insured 47-51136-3 Work Location of Insured(Only required if coverage is specifically limited to 1 d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e.,a Wrap-Up Policy) ty Number 202917229 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Travelers Indemnity Company of Connecticut City of Saratoga Springs 474 Broadway 3b.Policy Number of Entity Listed in Box"1a" Saratoga Springs,NY 12866 UB8J0772031826G 3c.Policy effective period 11i:su1ZUlti to 1173Ui4U1U 3d.The Proprietor,Partners or Executive Officers are JX included.(Only check box if all partners/officers included) [] all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box"3"insures the business referenced above in box"1a"for workers' compensation under the New York State Workers'Compensation Law. (To use this form, New York(NY)must be listed under item 3A on the INFORMATION PAGE of the workers'compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above 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 canceled 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 the 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 Workers'Compensation contract of insurance only while the underlying policy is in effect. Please Note: Upon cancellation of the workers'compensation 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 Workers'Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers'Compensation Law. 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 the coverage as depicted on this form. Approved by: Marc A.Bergeron (P'nt name of authorized representative or licensed agent of insurance carrier) Approved by: ?i/ CLt—e— a. F/7//,' (Signature) (Date) Title: Authorized Representative Telephone Number of authorized representative or licensed agent of insurance carrier: 781-935-8480 Please Note:Only insurance carriers and their licensed agents are authorized to issue Form C-105.2. Insurance brokers are NOT authorized to issue it. C-105.2 (9-17) www.wcb.ny.gov Workers' Compensation Law Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured. 1. 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 a hazardous employment defined by this chapter, and notwithstanding 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 compensation for all employees has been secured as provided by this chapter. 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 compensation to any such employee if so employed. 2. 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 a hazardous employment defined by this chapter, 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 compensation for all employees has been secured as provided by this chapter. C-105.2 (9-17) REVERSE 4Va,.. Workers' CERTIFICATE OF INSURANCE COVERAGE ra c 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 1 a.Legal Name&Address of Insured(use street address only) lb.Business Telephone Number of Insured TRINITY BUILDING AND CONSTRUCTION MANAGEMENT CORP. (781)938-0008 ONE JEWEL DRIVE STE 322 WILMINGTON,MA 01887 1c.Federal Employer Identification Number of Insured or Social Security Work Location of Insured(Only required if coverage is specifically limited to Number certain locations in New York State,i.e.,a Wrap-Up Policy) 202917229 ^ 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) New York State Insurance Fund(NYSIF) CITY OF SARATOGA SPRINGS 474 BROADWAY 3b,Policy Number of Entity Listed in Box"la" SARATOGA SPRINGS,NY 12866 DBL 6003 25-6 3c.Policy effective period 11/30/2018 to 11/30/2019 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 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 described above. Date Signed 8/7/2019 By �- . ~' (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number (866)697-4332 Name and Title Melissa Jensen,Director of Disability insurance Unit IMPORTANT: If Box 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 mailed for completion to the Workers' Compensation Board, DB 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 58 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 (Signature of Authorized NYS Workers'Compensation Board Employee) Telephone Number Name and Title 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 013-120.1. Insurance brokers are NOT authorized to issue this form. DB-120.1 (10-17) Certificate Number 561248 Additional Instructions for Form DB-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 la"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 Worker's 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 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 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 ail employees has been secured as provided by this article. 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