HomeMy WebLinkAboutBP18-167PERMIT #
SECTION
TYPE OF WORK
Joe LOCATION _
EST. COST
V/co #.
TCO # FEE DATE
I try .ATE: I l� Exp:
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DATE INSP
FOOTING
FOUNDATION
FRAMING
RGH FRAMING
INSULATION
PLUMBING
RGN PLUM51.
GAS ®-'
SPRINKLER
LOW -VOLT C�
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AS BUILT
FINAL
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OTHER APPROVALS
ARB
BOT
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ZBA
OTHER
Open Permit Letter Sent
giioi19
VILLAGE OF RYE BROOK
WESTCHESTER COUNTY, NEW YORK
NO: 25-032
Certtf trate of Ocrupaucp
sThis is to certify that R �G
of, having duly filed an application on
�hiVr,�a v�f 7. 20 requesting a Certificate of Occupancy for the premises known as,
qo A Rye Brook,NY, located in a o , - Zoning
District and shown on the most current Tax Map as Section: ) -0 / Block: Lot:
and having fully complied with the requirements of the Building Code and the Zoning Ordinance under Building
Permit No. —/CL /wi, issued l a 1a 20 , such authority and permission is hereby granted
to the property owner to lawfully occupy or use said premises or building or part thereof listed under the following
New York State Classifications, Use: ST U Construction: ,
for the following purposes: Ir
l'Y�-P- r rim lour l�y-P l
Subject to all the privileges, requirements, limitations, and conditions prescribed by law, and subject also to the
following:
This certificate does not in any way relieve the owners or any person or persons in possession or control of the premises,
building,or any part thereof from obtaining such other permits or licenses as may be prescribed by law for the uses or purposes
for which the building or premises is designed or intended. Furthermore, it does not relieve such owners or persons from
complying with any lawful order issued with the object of maintaining the premises or building in a safe and lawful condition.
No changes or rearrangement in the structural parts of the building or in the exit facilities shall be made,and no enlargement,
whether by extending on any side or by increasing in hei shall be made hall the building be moved from one location
to another until a permit to accomplish such change has ee obtained o the uilding Inspector.
Building Inspector,Village of Rye Brook: Date: MAR 0 4 2025
D IECD�I �
FEB -7 2025 BuiL NT 6 �7
VILLAGE OF RYE BROOK OFATX LVUED: _
BUILDING DEPARTMENT 938 KING YORK 10573 DATE:,-,)
FEE:42 &MIK
APPLICATION FOR CERTIFICATE OF OCCUPANCY,CERTIFICATE OF COMPLIANCE,
AND CERTIFICATION OF FINAL COSTS
2 I0% OW ON= eOWUMM W A" PM » PRIOR TO THIC FINAL nMPXClIOM
1N11N111111/N111N11NIIIN/1N11/II/NIIN1111111N11/IN111NINIINIIN111N11►111/1N/1N1111 N NOIN1111NIN/NN11•
Address: 90 South Ridge Street
occupancy/Use: Commercial Parcel ID#: 141.27-1-9 Zone:
Owner: RSP Group LLC c/o Cornerstone Management Address:P.O.Box 277,Rye,NY 10580
P.EJR.A.or Contractor FIP Construction Inc. Address: 1536 New Britain Avenue,Farrring0n,CT 06032
Person in responsible charge. Allan Cox Jr. Address: 1536 New Britain Avenue,EMM t CT 06032
Application is hereby made and submitted to the Building Inspector of the Village of Rye Brook for the issuance of a
Certificate of Occupancy/Certificate of Compliance for the structwWconstruction/alteration herein mentioned in accordance
with law:
STATE OF NEW YORK,COUNTY OF WESTCHESTER as:
Allan Cox Jr. 1536 New Britain Avenue
being duly sworn,deposes and says that helahe resides at
(Rini Nerve orA.Wicmt) (No.ud Street)
h, Farmington ,in the County of Hartford in the State of CT ,that
(CitylTown/village)
he/she has supervised the work at the location indicated above,and that the actual total cost of the worst,including all site improvements,
labor,materials,scaffolding,fixed equipment,professional fees,and including the monetary value of any materials acid labor which may
have been donated gratis was:$ 40,000
for the construction or altetad n of:: .E-1(18"908 meter room MOyatiOn
Deponent further states that he/she has examined the approved plena of the struodue/worlc herein referred to for which a Certific ue of
Occupancy/Compliance is sought,and that to the best of his/her knowledge and belief,the structure/work has been erecteftompleted in
accord-a—with the approved plats and any amendments thereto except in so far as variations therefore have been lcgally authorized.and
as erected/completed complies with the laws governing building construction.Deponent further understands that it shall be unlawfid for an
owner to use or permit the use of any building or premises or part thereof hereafter created,erected,changed,converted or enlargod,wholly
or partly,in its use or structure until a Certificate of Occupancy or Certificate of Compliance shall have been duly issued by the Building
Inspector as per§250-10.A.of the Code of the Village of Rye Brook.
Sworn to before me this 10' Sworn to before me this 15th
day of 0 )a 20 2-_ day of Ja 2025
I.
Signsturo of Property Owns of Appliant;
A—,ail „ 1A/b.4h1rit Allan Cox Jr.
t Ydune of Property Owm Print None of Applicant
otary Pablie
Jessica Barkley 3YLVIC MORIN
rrioa ! OIBAM26020 Nehrr ra11e,ldledGasseieat
No"> .So of New YakL4
M7 h�a BtI�Yw 1131RW .
W CmeAnim Bl*jm:hone 20,
�E BRq)
1982 BUILDING DEPARTMENT
❑BUILDING INSPECTOR
ElASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK
❑CODE ENFORCEMENT OFFICER 938 KING STREET • RYE BROOK,NY 10573
(914) 939-0668 FAx (914) 939-5801
www.ryebrook.org
- - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - -
ADDRESS :- 1-0 SOylu-, DATE: u Z
PERMIT# 9 I q y ISSUED: SECT: (. 7 BLOCK: LOT: /
LOCATION: OCCUPANCY:
❑ VIOLATION NOTED THE WORK IS... Q`ACCEPTED ❑ REJECTED/ REINSPECTION
❑ SITE INSPECTION REQUIRED
❑ FOOTING
❑ FOOTING DRAINAGE
❑ FOUNDATION
❑ UNDERGROUND PLUMBING NOTES ON INSPECTION:
❑ ROUGH PLUMBING
❑ ROUGH FRAMING
❑ INSULATION i
NATURAL GAS NEW
❑ L.P. GAS
❑ FUEL TANK
❑ FIRE SPRINKLER
❑ FINAL PLUMBING
❑ CROSS CONNECTION
❑ FINAL
❑ OTHER
QyE BRC�v�
BUILDING DEPARTMENT
❑BUILDING INSPECTOR
,]ASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK
❑CODE ENFORCEMENT OFFICER 938 KING STREET . RYE BROOK,NY 10573
(914) 939-0668 FAx (914) 939-5801
www ryebrook.org
- - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - -
ADDRESS :- �O JC7(�( L 51• DATE:
PERMIT# ? 7 Z C. -7 ISSUED:/D- 1I- i SECT: ? BLOCK: LOT:
LOCATION: h P it tr-z/� OCCUPANCY:
❑ VIOLATION NOTED THE WORK IS... ❑ ACCEPTED ❑ REJECTED/ REINSPECTION
❑ SITE INSPECTION REQUIRED
❑ FOOTING
❑ FOOTING DRAINAGE
❑ FOUNDATION
❑ UNDERGROUND PLUMBING NOTES ON INSPECTION:
❑ ROUGH PLUMBING
❑ ROUGH FRAMING
❑ INSULATION
❑ NATURAL GAS
❑ L.P. GAS
❑ FUEL TANK
❑ FIRE SPRINKLER
❑ FINAL PLUMBING
❑ CROSS CONNECTION
FINAL
❑ OTHER
BRCv�
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1932 BUILDING DEPARTMENT
0 BUILDING INSPECTOR VILLAGE OF RYE BROOK
0 VILLAGE ENGINEER 938 KING STREET RYE BROOK,NY 10573
0 ASSISTANT Buu.DING INSPECTOR (914) 939-0668 FAx(914) 939-5801
- - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - -- - - - -- -
Y`
qn
ADDRESS: r� 1 DATE:
PERMIT# - ISSUED: ICA l a $ECT: 141 BLOCK: LOT: 9
LOCATION: �q 5.4 -'-) OCCUPANCY: r3
O VIOLATION NOTED THE WORK IS... [4—ACCEPTED ❑ REJECTED/REINSPECTION
❑ SITE INSPECTION W( \ REQUIRED
D FOOTING
❑ FOOTING DRAINAGE
❑ FOUNDATION
❑ UNDERGROUND PLUMBING NOTES ON INSPECTION:
ft'ROUGH PLUMBING
9--ROUGH FRAMING �l S I
❑ INSULATION
❑ NATURAL GAS
❑ L.P. GAS
D FUEL TANK
❑ FIRE SPRINKLER
❑ FINAL PLUMBING
D FINAL
0 OTHER
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BUILDING DEPARTMENT
VILLAGE OF RYE BROOK
938 KING STREET RYE BROOK,NY 10573 JAN 15 2019 l t{
(914)939-0668�FAX(914)939-5801
Nti�wWAI—v roo .ors
PLUMBING PERMIT APPPLICATION
F012 OFFICE USE ONLY I?i l' ?: C J�_ 1 1 PP#:
Approval Date: vot- Permit Fee: S I—7
Approval Signature: Other:
Disapproved:
(fees are non-refundable)
#k#kkkkkkk#kI:+kk+k*kKkk*:k:k*****:Kok:kKA*********�#*#*W;<T:i::Fa�*T*>, *��*=k�k•r+:;:k�T�#i•R�-vr-k?>::�kR;<#*:kT'r*kk*#'*%F
Application dated, 1 013 11201 8 is hereby made to the Building Inspector of the Village of Rye Brook NY,for the issuance of
a Permit to install and/or remove Plumbing as per detailed statement described below.The applicant&property owner,by signing this
document agree that said plumbing work will be in conformance with all applicable Federal,State,County and Local Codes.
1.Address: 90 South Ridge Street SBL: 141.27-1-9 Zone:
2.Proposed Work: Install vent lines for gas regulators
3.Property Owner: RSP Group LLC. Address: PO Box 277 Rye, NY 10580
Phone#: 914-937-1230 Cell #: email:
4.Master Plumber: Steven A. Salierno Address: 635 Old White Plains Rd Tarrytown, NY 10591
Lic.#: 1160 phone#: 914-713-3040 Cell#: 914-374-3242 email: archerplumbing@gmail.com
Company Name: Archer Plumbing & Heating Inc. Address: 635 Old White Plains Rd Tarrytown, NY 10591
INDICATE FIXTURES& LINES TO BE INSTALLED AS PER THE FOLLOWING SCHEDULE:
Location Water Urinals Drinking Sinks Showers Bath Laundry Domestic Fire Sanitary Natural/ Other* Total
Closets Fountains Tubs Tubs Service Service Sewer LP Gas
Basement
1st Floor
2nd Floor
3`d Floor
4F Floor
5-6 Floor
Exterior
5.* List Other Equipment/Provide Details:
Notarized Signatures Required Next Page
-I-
6/1/18
STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as:
skJCN Sa.1`1 uqw ,being duly sworn,deposes and states that he/she is the applicant above named,
(print name of individual signing as the applicant)
and further states that(s)he is the legal owner of the property to which this application pertains,or that(s)he is the
& Gn4M for the legal owner and is duly authorized to make and file this application.
(indicate architect,GEtor agent,attorney,etc.)
That all statements contained herein are true to the best of his/her knowledge and belief,and that any work performed,or use
conducted at the above captioned property will be in conformance with the details as set forth and contained in this application
and in any accompanying approved plans and specifications,as well as in accordance with the New York State Uniform Fire
Prevention&Building Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances and regulations.
By signing this application,the property owner further declares that he/she has inspected the subject property,and that to the best
of his/her knowledge there are no roof drains,sump pumps or other prohibited stormwater or groundwater connections or sources
of infiltration into the sanitary sse)wer system on or from the subject property.
Sworn to befor me this 7 Sworn to before me this (/D
day of 2V ti,20 day ofk2,�,�in. , ,20��
ignature of Property wner Signat pp is
b1zi An
�p �1�}1 0 Zs (�1 e-��'1 a 1s�-, [�f C.�O� SkVCA J(L`1 tif r10 , ACCh e-- Pkk"h !S
Pr' ame of P p rty Owner Print Name of Applicant 5
tary Public NUOLO Notary Publ' TANYA BASALYGA
NOWT FIEWSft/ed New York Notary Public, State of New York
N'`eJIMM Registration#01 BA6290293
ce. amftd In��rc°u�e� Qualified In Westchester County
pim�prH�'��// Commission Expires Oct. 7.20
This application must be properly completed in its entirety and must include the notarized signature(s) of
the legal owner(s)of the subject property, and the;applicant of record in the spaces provided. Applications
not properly completed in its entirety and/or not properly signed.shall be deemed null and void and will be
returned to the applicant.
-2-
6/t/18
Mike Izzo
From: Mike Izzo
Sent: Tuesday, September 17, 2019 8:56 AM
To: 'Frankjon Albanese'
Cc: tgerardi@ryebrook.org; Liz Caruso
Subject: RE: 90 S Ridge St - Permit 18-167 Extension Request
Dear Frankjon,
Please note that your request for a six (6) month extension to the subject permit has been approved. Further note the
new expiration date is;April 12, 2020. Please arrange for all work to be completed and successfully inspected, and for all
paperwork&fees to be remitted to the Village such to facilitate the issuance of the Certificate of Occupancy on or before
that date.
Thank you.
lff,eAad(l /ZZO
Building & Fire Inspector
Village of Rye Brook, NY
Phone—(914) 939-0668
Fax—(914) 939-5801
mizzo(&ryebrook.org
From: Frankjon Albanese [mailto:frankjon.cornerstone@gmail.com]
Sent: Friday, September 13, 2019 12:31 PM
To: Mike Izzo<Mlzzo@ryebrook.org>
Subject:90 S Ridge St- Permit 18-167 Extension Request
Hi Mike,
Could I please get a six month extension on permit BP 18-167 for 90 S Ridge St?Greenwich Hospital and ConEd take
forever to do anything and we have had a number of issues.Thanks.
Frankjon Albanese
R CORNERSTONE
MANAGEMENT
PO Box 277
Rye, NY 10580
914-906-1100 Direct
Cornerstone Management, LLC-CONFIDENTIALITY NOTICE: This electronic message is intended to be viewed only by the
individual or entity to whom it is addressed. It may contain information that is privileged,confidential and exempt from disclosure
under applicable law. Any dissemination,distribution or copying of this communication is strictly prohibited without our prior
permission. If the reader of this message is not the intended recipient,or the employee or agent responsible for delivering the message
to the intended recipient,or if you have received this communication in error,please notify us immediately by return e-mail and delete
the original message and any copies of it from your computer system.
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VILLAGE OF RYE BROOK
MAYOR 938 King Street, Rye Brook, N.Y. 10573 ADMINISTRATOR
Paul S. Rosenberg (914) 939-0668 Fax (914) 939-5801 Christopher J. Bradbury
www.ryebrook.org
TRUSTEES BUILDING & FIRE
Susan R. Epstein INSPECTOR
Stephanie J. Fischer Michael J. Izzo
David M. Heiser
Jason A. Klein
September 10. 2019
Via I"Class Certified Mail
RSP Group LLC
Frankjon Albanese
P.O. Box 277
Rye, New York 10580
Re: 90 South Ridge Street, Rye Brook, New York 10573
Notice of$500.00 Fee for Expired Permits
Open Building Permit#18-167 Issued: 10/12/2018 - Expiration Date: 10/12/2019
Dear Property Owner,
Please allow this letter to serve as a reminder that your open permit(s) noted above, as is the case with all
Building Permits issued by the Building Department must be closed out with a Certificate of Occupancy
or Certificate of Compliance in accordance with §250-IO.A. of the Code of the Village of Rye Brook.
Building Permits have a life of twelve (12) months and the expiration date is noted on the front of the
permit.
Please be advised that should you fail to properly close out your permit(s) in accordance with the law,
effective November 1, 2009 the Village will be imposing a $500.00 Administrative Fee in connection
with all open expired Building Permits issued after January 1, 2003. Please note that this Administrative
Fee applies to each individual permit and must be remitted in addition to any other required fees
associated with closing the permit(s). as well as any court imposed fines should a summons(es) be issued.
Thank you for your attention in this matter, and please feel tree to contact this office should you require
any further information.
Michael J. Izzo
Building& Fire Inspector
mizzo(a-)ryebrook.org
/ec
cc: Steven E. Fews, Assistant Building Inspector
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Building Pernut Check List&Zoning Analysis
Address: GL 0 —� t 't--> S S`t SBL• t`i k •ZZ l 'C(
Zone: - S Use: ,��- Const.Type: Other.
Submittal Date: I �j Revisions Submittal Dates:
Applicant: _,S? ea,o -i.-
Nature of WorkN i4 t e x 1 N G A J �.�t�?�./l_�Z.�•-�,
Reviews:ZBA: O C T I 110 1 8 PB: BOT: Other.
NEED OK
( ) FEES:Filing. Z50• 1 BP: '7'FD. C/O: Legalization:
( ) ( �APP: Date Stamped. Properly Signed: SBL Verified H.O.A.Approval:-
( ) ( ) Scenic Roads: Steep Slopes: Wetlands: Storm Water Review: Street Opening:
( ) ( ) ENVIRO:Long. Shorn Fees: N/A:
( ) ( ) SITE PLAN:Topo: Site Protection S/W Mgmt.: Tree Plan: Other.
( ) ( ) SURVEY:Dated: Current: Archival: Sealed. Unacceptable:
( ) (� PLANS:Date Stamped ✓ Sealed. Copies: Z Electronic: Other.
�J (�License: Workers Comp: ✓ Liability: Loltomp.Waiver. Other.
( ) ( ) CODE 753#: Dated: N/A:
(•� ( ) HIGH-VOLTAGE ELECTRICAL:Plans: Permit: N/A: Other.
( ) ( ) LOW-VOLTAGE ELECTRICAL:Plans: Permit N/A: Other.
FIRE ALARM/SMOKE DETECTORS:Plans: Permit: H.W.I.C.:_Battery:_Other.
( ) ( ) PLUMBING:Plans: Permit: Nat.Gas: LP Gas: N/A/: Other.
( ) ( ) FIRE SUPPRESSION:Plans: Permit: N/A: Other.
( ) ( ) H.V.A.C.: Plans: Permit: N/A Other.
( ) ( ) FUEL TANK:Plans: Permit: Fuel Type: Other.
O O 20I6 NY State ECCC: N/A Other.
( ) ( ) Final Survey Final Topo: RA/PE Sign-off Letter: As-Built Plans: Other.
( ) ( ) BP DENIAL LETTER C/O DENIAL LETTER: Other.
( ) ( ) Other.
( )ARB mtg.date: approval• notes:
( )ZBA mtg. date: approval:- notes:
( )PB mtg. date: approval: notes:
REQUIRED EXISTING PROPOSED NOTES p
Area: =18
Circle:
FronM�
Front:
Front:
Sides:
Rear.
Main Cow.
Accs.Cor.
Ft.H Sb:
Sd.H Sb:
GFA.
Tot.ImR:
Ft.Im :
Paz
Height/Stories:
notes:
Check List For Release of Building Permits
Address: 90 �vfh glcoe
Owner/Applicant:
Phone Ws:
Dates Attempted To Contact Owner/ Applicant:
)o1111100 Comments: cp�w ltd ouwr
I
Comments:
Comments:
NEED:
( ) Building Permit Fee $
( ) UFPO #
( ) WC Home Improvement License
Y
Comp Waiver
( ) General Contractor's Contact Information
( ) Fire Sprinkler Plans (2)
( ) Fire Sprinkler Application
( ) Fire Sprinkler Permit Fee
( ) Estimated Cost $
( ) SWO Fee $
( ) Legalization Fee $
( ) Other
Tara 0
Tara Gerardi
From: Tara Gerardi
Sent: Thursday, October 11, 2018 11:41 AM
To: 'coxa@fipconstruction.com'
Cc: Cornerstone (frankjon.cornerstone@gmail.com)
Subject: Building Permit Application - 90 South Ridge Street
The building permit application has been approved by the Building Inspector, before I can issue the
building permit the following items must be submitted to our office,
1. Liability insurance (the Village Of Rye Brook must be the certificate holder)
2. Workers compensation on a NY State Board form (C105-2 or U26.3)
TARA A. GERARDI
SENIOR OFFICE ASSISTANT, OFFICE MANAGER
VILLAGE OF RYE BROOK
938 KING STREET
RYE BROOK, NEW YORK 10573
OFFICE (914) 939-0668
FAx (914) 939-5801
Ace I 12/ 6/2 CERTIFICATE OF LIABILITY INSURANCE DATE( 26/2YY01 7
Ill
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(les)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 ondorsemer s.
PRODUCER CONTACT
The Watts Group, LLC. PHONE lgliaea J Moro• FAx
65 La Salle Road (AIC.No.I!it): (960) 231-72SO x4 I(A/C,Ng):(960) 231-7240
Suits 209 AODRIE$S: amoreeethes,attim.cas
West Hartford CT 06107
INSUR S AFFOROMOOOYi1MYi NAIC4
INSURERA.phoenix Insurance Company 2S613
INSURED INSURER B:Charter Oak Fire Insurance CO, 2S615
PIP Construction, Inc. -—
INSURER C:CN& Insurance Companies 20443
1536 New Britain Ave. INSURER D:Travelers IndealIt CO. Of _Au. 25666
Farmington CT 06032 INSURER E:Liberty 9\Lrplu2 Lines Ins. Co. _ _ 10725
INSURER I-:
COVERAGES CERTIFICATE NUMBER:Cert ID 951 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.
ILTR ADOLTYPE OF INSURANCE ii wvn SUER POLICY NUMBER I POLICY EFF POILICYAM1QVr EXP I LIMITS
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE = 1,000,000
DAMAGE TOCLAIMS-MADE UOCCUR CO-620M9777 01/01/2018101/01/2019_P_RSEa_gR 11 300,000
_ MED EXP(Artya peson) t 5,000
_ PERSONAL i ADV INJURY _ f 11000,000
OEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE t 2,000,000
POLICY[,jEC F-1 LOC PRODUCTS-COMP/OPAGG i 2,000.000
OTHER f
AUTOMOBLELIABIUTY COMBINED SINCA.F LIMIT
ffi acodernl $ 11000,000
B X ANY AUTO EA-620M9777 01/01/2015 01/01/20191 BODILY INJURY(Per person) $
OWNED SCHEDULED - -
AUTOS ONLY AUTOS I BODILY INJURY(Per accident) III
HIRED NON-OWNED PROPERTY DAMAGE
AUTOS ONLY AUTOS ONLY 1P6LlQEdeml 9 _
X Comp 6 Coll X 41,000
du ti UK/IIIK E 1,000,000
C XIUMBRELLALIAB X OCCUR 6050518956 01/01/201t 01/01/2019 EACHOCCURRENCE S 10,000,000
EXCESS LIAB CLAIMS-MADE AGGREGATE 3 10,000,000
DED TX I RFTENTIONS 10,000 let la er umbrella s
ID AND
COMPENSATION H-
ANDEMPLOYERTUABLITY YIN UB-9J51616A 01/01/201 01/01/201 X R
ANYPROPRIETORIPARTNER/EXECUTWE E L EACH ACCIDENT i 11000,000
OFFICERIMEMBEREXCLUDED7 FNINIA ----
(Mandatory In NH) E L.DISEASE-EA EMPLOYEE 1 1,000,000
tt ea,descnbe under --
(,RIPTI(1NOF OPERATIONS DeloW E.L DISEASE-POLICY OMIT $ 11000,000
B 2nd Layer Umbrella 1000291015-01 01/01/201 01/02/2019 tad Layer Umbrella = 15,000,000
t
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is requlredl
RE: Building Permit
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Village of Rye Break ACCORDANCE WITH THE POLICY PROVISIONS.
Building Department
938 King Street AUTHORIZED REPRESENTATIVE
Rye Brook NY 10573
01988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
Page 1 of 1
STATE OF NEW YORK
WORKERS' COMPENSATION BOARD
CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE
1 a. Legal Name and address of Insured(Use street address only) l b. Business Telephone Number of Insured
FIP Construction,Inc. (860)470-1800
1536 New Britain Avenue
Farmington,CT 06032 lc.NYS Unemployment Insurance Employer Registration
Number of Insured
Work Location of Insured (Only required if coverage is specifically 63-61385 2
limited to certain locations in New York State, i.e. a Wrap-Up 1 d. Federal Employer Identification Number of Insured or
Policy) Social Security Number
06-0847507
2.Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier
Coverage(Entity Being Listed as the Certificate Holder) TRAVELERS INDEMNITY COMPANY OF
AMERICA
Village of Rve Brook
Building Department 3b. Policy Number of entity listed in box"la":
938 King Street UB-9J51616A
Rye Brook,NY 10573 3e. Policy effective period:
01/01/2018-01/01/2019
3d. The Proprietor,Partners or Executive Officers are:
X included. (Only check box if all partners/officers included)
all excluded or certain partners/officers excluded.
3e. Demolition is: (Definition of Demolition on Reverse)
❑X included.
excluded.
This certifies that the insurance carrier indicated above in box "Y' insures the business referenced above in box "]a" 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"T',
The Insurance Carrier will also notes the above certificate holder 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 eliminute the insured
from the coverage indicated on this Certificate. (These notices may be sent by regular mail.) Otherwise, this Certificate is valid for a
maximum of one year after this form is approved by the Insurance carrier or its licensed agent.
Please Note: Upon the 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: _i I ael 1:. Watts
Z(11n,,name o nhonicd rcprescntati%c or licensed agent of insurance carrier)
Approved by: / /�� 12/26/2017
(Signature) (Date)
Title: President—The Watts GrouV, LLC.
Telephone Number of authorized representative or licensed agent of insurance carrier(860)231-7250:
Please Note:Only insurance carriers and their licensed agents are authorized to issue the C-105.2 form. Insurance brokers are NOT
authorized to issue it.
C-105.2(12-03)
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