FILED: NEW YORK COUNTY CLERK 05/25/2021 11:11 AM
`NYSCEF DOC. NO. 418
`
`INDEX NO. 657487/2017
`
`RECEIVED NYSCEF: 05/25/2021
`
`Buildings
`
`PGL1:
`
`Project
`
`Specific
`
`General
`
`Liability
`
`Insurance
`and
`
`Affirmation
`
`Summary
`
`Generated by the online DOB tool
`
`This
`
`document
`
`must
`
`be
`
`General
`
`Liability
`
`Insurance
`
`submitted
`coverage
`
`with
`
`an ACORD
`the
`project
`
`for
`
`Certificate
`
`described
`
`DEPT BLDGS
`
`121329222
`
`Job Number
`
`SC112843020
`
`summarizing
`below.
`
`can
`
`ode
`
`.
`
`the
`
`ecet!en
`
`Information
`
`Required for all applications.
`
`House No(s) 101
`Borough Manhattan
`
`Street Name West 28th Street
`Block 804
`Lot 34
`
`BIN 1088896
`
`CB No. 105
`
`2 Project Specific
`
`Insurance
`
`R5ÿü;i5méñt
`
`The required insurance is calculated based on information provided by the applicant.
`
`Yes
`
`No
`
`1 or 2 family home?
`Depth of Excavation < 12'?
`Proposed Height < 35'?
`Proposed construction on lot line with an existing structure?
`Is a Tower Crane to be used?
`
`Height of proposed construction 296 ft
`Number of stories of proposed construction 28
`Height of tallest adjacent building 103 ft
`Number of stories of tallest adjacent building 5
`Permit Type NB/Major AIt
`
`Calculated Project Specific GL Insurance
`
`-;--
`
`25M
`
`3
`
`Required for all applications.
`pp!!cent
`Statement
`and Signatures
`The information in this application is correct and complete to the best of my knowledge and I assume responsibility for all statements on this
`form.
`If I am found after hearing to have knowingly or 66gägâñay made a false statement on this or any other document
`I understand that
`I also
`to fine, Imprisonment, and/or barred from filing further documents with the Department.
`I may be subject
`submitted to the Department,
`to give to a city employee, or for a city employee to accept, any benefit, monetary or otherwise, either as a gratuity for
`understand it is unlawful
`properly performing the job or in exchange for special consideration.
`Notarization (required if not licensee)
`Name Walter Beal
`State of New York, County of:
`Swom to or affirmed under penalty of perjury
`
`Licensee
`
`PUBL C
`
`*.7 t
`6 *
`
`Registration/Tr cki
`
`mber 605946
`
`Signature
`
`Date
`
`day of
`
`Î*t
`
`20{4f
`
`Notary Signature
`
`15
`Required for all applications.
`Brokers C r
`fication
`The undersigned insurance broker represents to the City of New York that the attached Certificate of Insurance is accurate in all material re-
`spects, and that the described insurance is effective as of the date of this Certification. With regard to the liability insurance (including excess or
`umbrella insurance) described there, the undersigned further represents that:
`The total per occurrence and aggregate limit ded!cetad to the DJolect is: $
`million
`[Total of all primary, umbrella and excess policy limits dedicated to project for which DOB permit is sought (or being renewed). Must be
`same or higher than "Calculated Project Specific GL Insurance Required" in section 2 above.]
`insured on these policies.
`The City of New York is additional
`ame of Broker
`
`Addre
`
`of Broker 3 .
`
`Sign
`
`o
`
`uth
`
`zed Broker
`
`itle
`
`uth ized Officer
`
`Notarization (required)
`State of New York, County
`Swom to or affirmed under penalty
`20/ÿ/
`ay of
`
`perjury
`
`Notary Signatur
`
`Notary Seal
`
`No. 018U5058075
`in Suffolk County
`Ouelified
`Commission
`April01.-
`Expirg,
`
`EXHIBIT
`
`05/11
`
`1 of 2
`
`

`

`FILED: NEW YORK COUNTY CLERK 05/25/2021 11:11 AM
`NYSCEF DOC. NO. 418
`RD
`A
`
`INDEX NO. 657487/2017
`
`RECEIVED NYSCEF: 05/25/2021
`
`Corporation
`
`NY
`
`11803
`
`Corp,
`36th
`
`LLC
`Street
`
`,
`
`2nd
`
`Floor
`
`NY
`
`INSURANCE
`OF LIABILITY
`CERTlFICATE
`3
`THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDE
`T S
`OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
`CERTIFICATE DOES NOT AFFIRMATIVELY
`BELOW.
`THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE !SSU!NG INSURER(S), AUTHORIZED
`REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
`to
`IMPORTANT:
`If the certifiCate
`If SUBROGATION IS WAIVED, subject
`is an ADDITIONAL
`the policy(ies) must be er.dcrasd.
`holder
`INSURED,
`rights to the
`the terms and cond!tione
`certain policies may require an endorsement.
`A statement
`of
`on this certificate
`does not confer
`the policy,
`holder
`in lieu of such endoreemenwa).
`certificate
`CT
`PRODUCER
`GOrham
`Kelly
`NE p .
`Coverage
`(516)349-1333
`Vanguard
`GORNAMSVA"GUAPECOVERAGE.COM
`BLVD
`131
`SUNNYSIDE
`SUITE
`112
`INSURER(S)AFFORDINGCOVERAGE
`PLAINVIEW
`Marine
`NSuRERA :New York
`& General
`INSURED
`INSURERB :Starr
`& Liability
`Indemnity
`Springline
`& Liability
`INSURERc-American
`Guarantee
`149 West
`INSURERD:
`212-967-4150
`INSURERE:
`10018
`New York
`INSURERF :
`.
`NYCDOB
`NUMBER:14-15
`REVISION NUMBER:
`COVERAGES
`CERTIFICATE
`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 REQUlFEMENT, 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 POLIQIES. LIMITSSHOWN MAY HAVE BEENMEDUCED BY PAID CLAIMS.
`TYPEOFINSURANcE
`POLICYNUMBER
`(
`a
`GENERALLIABILITY
`X COMMERCIALGENERALUABILITY
`CLAIMS-MADE
`OCCUR
`ADDL INSD-BLKT
`
`No).(516)349-8667
`
`Ins
`
`Co
`
`NAIC#
`16608
`38318
`26247
`
`_.
`
`UMITS
`EACHOCCURRENCE
`$
`DAMAGETORENTED
`$
`PRFMISES(Eaoccurrence)
`MEDEXP(Anyoneperson)
`$
`PERSONAL&ADVINJURY
`$
`$
`GENERALAGGREGATE
`PRODUCTS- COMP/OPAGG $
`
`2,000,000
`50,000
`Excluded
`2,000,000
`4,000,000
`4,000,000
`
`SINGEELIMIT
`BODILYINJURY(Perperson) $
`BODILYINJURY(Peracculent)$
`PROPERTYDAMAGE
`(Peraccklent)
`
`$
`$
`$
`
`EACHOCCURRENCE
`AGGREGATE
`
`3,000,000
`3 ,000,000
`
`OTH.
`ER
`
`WCSTATU-
`TORYLIMITS
`E.L EACHACCIDENT
`$
`E.L DISEASE- EAEMPLOYEE$
`E.L DISEASE- POUCYUMIT $
`OCCUR/AGGREGATE
`
`$22,000,000
`
`A
`
`X
`
`3L201400001262
`
`B/5 /2014
`
`3/5/2015
`
`GEN'LAGGREGATEUMITAPPUESPER:
`POUCY
`LOC
`AUTOMOBILEUABILrry
`ANYAUTO
`L
`NED
`ULED
`HIREDAUTOS _ AUTOS
`NON-OWNED
`
`X OCCUR
`CLAIMS-MADE
`
`X UMBRELLALIAB
`EXCESSUAB
`RETENTIONS
`DED
`WORKERSCOMPENSATION
`ANDEMPLOYERS'LIASIUTY
`Y/ N
`ANYPROPRIETOR/PARTNER/EXECUTIVE
`N/ A
`OFFICER/MEMBEREXCLUDED?
`(MandatoryIn NH)
`Ifyes,describeunder
`DESCRIPTIONOFOPERATIONSbelow
`EXCESS LIABILITY
`
`C
`
`t/O 1000020266
`
`3/5 /2014
`
`3/5/2015
`
`4EC5932390-01
`
`B/5/2014
`
`3/5/2015
`
`I Lrequired)
`DES*RIPTIONOFOPERATIONS/ LOCATIONS/ VEHICLES(ntlachACORD101,AdditionalRemarksSchedule,If more
`OF THIS
`CO TRA‡TOR FOR THE 101 WEST 28TH STREET,
`THE COVERAGE IS BROAD ENOUGH TO COVER THE OPERATION
`PROJECT.
`NY 10001,
`MANHATTAN,
`HOLDER AND THE CITY OF NEW YORK ARE INCLUDED
`CERTIFICATE
`
`AS ADDITIONAL
`
`INSUREDS.
`
`CERTIFICATE
`
`HOLDER
`
`CANCELLATION
`
`NEW YORK CITY
`OF BUILDINGS
`ATTN:
`LICENSING
`280
`BROADWAY
`NY
`NEW YORK,
`
`DEPARTMENT
`
`UNIT
`
`10007
`
`SHOULD ANY OFTHEABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
`THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
`ACCORDANCEWITH THE POLICY PROVISIONS.
`
`AUTHORIZEDREPRESENTATIVE
`
`Joseph
`
`Sforzo/DEBBIE
`
`ACORD 25 (2010/05)
`1NS025(201005).01
`
`ACORD CORPORATION.
`©1988-2010
`The ACORD name and logo are registered marks of ACORD
`
`All
`
`rights
`
`reserved.
`
`2 of 2
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