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HomeMy WebLinkAboutBP19-104PEF4MIT #�� + �� DATE: EXP:�(2„�,�„?� SECTION � �� ��"� _BLOCK _ I LOT S�L�.__ TYPE OF WORK / 1 IC.(..r / 1 ' 10B LOCATION � f/� iC OWNER YV � [_(/I V ` c CONTRACTOR � 1 �� �' T. COST CO # - FEE G TCO # FEE _._ _BATE INSPECTION RECORD DATE FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION __ PLUMBING C..] RGH PLUMBING GAS O SPRINKLER ELECTRIC LOW -VOLT (� ALARM AS BUILT FiNAI I NSP OTHER APPROVALS ARa �..JC.� ���� � PBT ZBA /�/n' I OTHER �1Q7"-�'1 0 y � 3�� Expired Letter Sent 10/6/2022 -� 10%�22 FINISHED BASEMENT N07 APPROVED FOR USE AS A SEPARATE APARTMENT OR DWELLING UNIT EP IQ-13�/�i Is�"on ��eC�"ri�a,� �'iain�-ena.nce VILLA OF RYE BROOK WESTCHES COUNTY, NEW YORK No: 22-175 Certificate of ®ccupaucp This is to certify that H01- L C.C� J0 d/ LOVI of, having duly filed an application on ock b r /<D-Z� 20��requesting a Certificate of Occupancy for the premises known as, rc ! (—� C� , Rye Brook,NY, located in a Zoning District and shown on the most current Tax Map as Section: Block: r Lot: 5, and having fully complied with the requirements of the Building Code and the Zoning Ordinance under Building Permit No. Q— , issued c Y /6 20 J q , 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: V">prn , Construction: , for the following purposes: 1 s Subject to all the privileges, requirements, limitations, and conditions prescribed by law, and subject also to the following: FINISHED BASEMENT NOT APPROVED FOR USE AS A DWELLING UNIT 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 height shall be made,nor shall the g be moved from one location to another until a permit to accomplish such change has been obtai in Build' g Ins ctor. NOV 14 1021 Assistant Building Inspector,Village of Rye Brook: Date: REC ENE OCT 1 2 2022 3BUILDING DEPARTMENT For office use on1 :- PERMIT# VILLAGE OF RYE BROOK ISSUED: -/'? VILLAGE OF RYE BROOK 938 KING STREET,RYE BROOK,NEw YORK 10573 DATE: - 2)2 BUILDING DEPARTMENT (914)939-0668 FEE: PAID www,rypbrook.org APPLICATION FOR CERTIFICATE OF OCCUPANCY,CERTIFICATE OF COMPLIANCE, AND CERTIFICATION OF FINAL COSTS TO BE SUBMITTED ONLY UPON COMPLETION OF ALL WORK, AND PRIOR TO THE FINAL INSPECTION ►ttt►►it►i►►►ttttitt►i/itttti►►ii;►►►ti►►►i►it►Rt;►ttt;►Mitt►tttttii►►■i►i;;t►t►►►►t►t►ti/►tt►i;►■►►t►►►►►►ttitt►►itit►►♦/t;► Address: �('41 e ✓ate`C N v S Occupancy/Use:51 N (e_ tL Parcel ID#: �35• —�� Zone: Owner: Address: P.E./R.A. or Contractor: E ta\U'�- ,s Address: Person in responsible charge: �6 J ( oAr4111 Address: 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 structure/construction/alteration herein mentioned in accordance with law: STATE OF NEW YOR-K,,�COUNTY OF WESTCHESTER as: 4w� � ► I being duly swom,deposes and says that he/she resides at (Print Name of A can II � (No.and Street) in c (6es K ,in the County of ��PST xt P S-� � in the State of that (Ci /Town/Village) he/she has supervised the work at the location indicated above,and that the actual total cost of the work,including all site improvements, labor,materials,scaffolding,fixed equipment,professional fees,and including the monetary value of any materials and labor which may have been donated gratis was:$ for the construction or alteration of t�yvt Cx��( t° ST(Iv P N ►S he4 I �lY�iti Deponent further states that he/she has examined the approved plans of the structure/work herein referred to for which a Certificate of Occupancy/Compliance is sought,and that to the best of his/her knowledge and belief,the structure/work has been erected/completed in accordance with the approved plans and any amendments thereto except in so far as variations therefore have been legally authorized,and as erected/completed complies with the laws governing building construction.Deponent further understands that it shall be unlawful for an owner to use or permit the use of any building or premises or part thereof hereafter created,erected,changed,converted or enlarged,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 4cP6 AFIB Swom to before me this day of l , 20 z day of , 20 Sjjnature of'Property Owner � p Signature of Applicant 1/4 y ,e�4D Name of Property Own Print Name of Applicant No ary Public SHARI MELILLO Notary Public Notary Public,State of New York No.OIME6160063 8/12/2021 Qualifled In Westchester County Commission Expires January 29,2(Lj uQyE[3R(�k, 0 Zm w t7 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: \ �` ,/� DATE: PERMIT# 1 ISSUED: 6 6 "SECT: I-S . CK: LOT: LOCATION: �) N IS► �C` / G (� ►'CI lY (2era-7 6 - f OCCUPANCY: I ❑ VIOLATION NOTED THE WORK IS... FJ 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 al H 04 00 con fi 0-� MCI Co . 00 4.1 ONO 16 W 06, QI �l 41 W6 U 16(14;t 4.to U Cot 4.t- C.t;�6*4�t t*-- C;t; (S-P 4-op 4;4;t,- L- t;41 f. EEF yE, f3Rnv (� BUILIR $ MENT V LSID VILLAGE OF RYE OK JUN 11 2019 938 KrNc�, ET RYE B \ ,NY 10573 (914)9 939-5801 VILLAGE OF RYE BROOK orI BUILDING DEPARTMENT ELECTRICAL PERMIT APPLICATION Westchester County Master Electricians License Required FOR OFFICE USE ONLY BP#: J 1 _1 01� EP#: 'q—I3q Approval Date: juN 1 2 2019 Permit Fee: $ '15 0 A Approval Signature: Other: Disapproved: (fees are non-refundable) Application dated, /71*7*/ 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 electrical equipment, wiring, fixtures,or to perform other high or low voltage electrical work as per the detailed statement described below. The applicant & property owner, by signing this document agree that all electrical work performed will be in conformance with all applicable Federal, State,County and Local Codes. 1.Address: Q y c- g ra o/k /✓,/ SBL: j3,5 '-4_"' 1 5.jp Zone: 2.Property Owner: (40 Li g i"�4 L o.v t I-f Address: '-e- L ct n e- Boo o!.f N / Phone#: C1 (`( -7 7 2 - 6 L(9 ( n Cell#: email: 3.Master Electrician: IJ a Address: 17C .S'f- Qi on k .P,X /O1l S Lic.#: S-G f Phone#: Cell#: `��7-���' SSD�/ email: k)rj y,de_ CZ 6,j 5 f Oka x . Cw,-►^ Company Name: /)I bi f 1_(c L Address: qS 3 /'. 7 r S t' 4.Proposed Electrical Work/Fixture Count: IS CC•,cif A c 3 2 �tit 2 3 ot.(1(c t- /1 STATE OF NEWYORK, COUNTY OF WESTCHESTER ) as: NC, y J e C/� • I S 'tom/1 ,being duly sworn,deposes and states that he/she is the applicant above named,and does further (print name of individual signing as the applicant) state that(s)he is the legal owner of the property to which this application pertains,or that(s)he is the for the legal owner and is duly authorized to make and file this application. (indicate architect,contractor,agent,attorney,etc.) The undersigned further states 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. Sworn to before me this Sworn t fore me this day of 20 day of 20 Signature of Property Owner Signature o Ap//plicant q d C ASfd�1 Print Name of Property Owner Name of Applican Notary Public Notary Public SHARI MELILLO Notary Public,State of New York No.01 M E6160063 Oualiffed in Westchester County Commission Expires January 29.20 3/21/19 STATEWIDE • Service With bitegril.i 0:0 Main Street,Fishkill, NY 12524 SWIS JOB APPLICATION0. Office Use Elect.Permit# _ Date (�/_ /I /' 3 Bldg Permit# 9 0 AM Sq Ft Temp# Utility ID# Final Certificate#City/Village ^ e roa / Zip /0 S— 7 3 Township R County �►<_'S Ickes � Address ( �j r Ch / /�� Cross Street e ion Block Lot L � Owner Name/Address(If different than above) I ' v I Contact Number `1 /'/_ 77 2- C�( 9 oWG � i [3'Basement ❑ 1st Fl. ❑2nd Fl. ❑3rd Fl. ❑More Than 3 Fl. ❑Garage ❑Attic ❑Outside Residential ❑Commercial Receptacles Special Recept GFCI AFCI Switches Dimmers Smoke Alarms Carbon Monox Hood Trash Compact Amt Amps I i C, Range(s) Cooktop(s) Oven(s) Dishwashers Refrigerator Disposal Microwave Warm Draw Incandescent Fluorescent SERVICE Amperage Voltage 1 P 3P #Meters #Disconnect ❑Underground ❑New ❑Reconnect ❑Overhead ❑Change ❑Visual Re-Inspection ❑ Safety Re-Inspection ❑ Re-Inspection Additional Information p C C� CDMCE JUN 11 2019 VILLAGE OF RYE BROOK BUILDING DEPARTMENT This application is valid for one(1)year from the date received by SWIS.This application is intended to cover the above listed items to be inspected,if at any time of inspection additional items have been installed,you are authorized to make the inspection and adjust the fee for the additional items inspected.The applicant declares that there is no open applications for the above address with any other inspection company.The applicant,owner or authorized agent agrees to all the above terms and conditions as set forth for the application. Inspector Date Finalized Inspector# Contractor Y �1� / I S ,vr Date G �� I �/ Signature v l-� Address — City/State = Zip Code License# S G i Phone# 6 S S S D q C � State Wide Inspection Services 1080 Main Street F202-1, 12524 owl"Uff 845 202-722424 Phone STATE WIDE INSPECTION SERVICES 914-219-1062 Fax Email: office(abswisny.com Service With Integrity Website: www.swisny.com BY THIS CERTIFICATE OF COMPLIANCE STATE WIDE INSPECTION SERVICES CERTIFIES THAT: Upon the application of: Upon Premises Owned by Gilston Electrical Maintenance Corp Howard Lavitt Jason Gilston 1 Birch Lane 8 Fieldcrest Drive Rye Brook, New York 10573 New City, New York 10956 Located at: 1 Birch Lane Rye Brook, New York 10573 Certificate Number: 2019-3947 Electrical Permit Number: 19-139 Section:135.42 Block:1 Lot:5.18 BDC:844 Building Permit Number: 19-104 A visual inspection of the electrical system was conducted at the Residential occupancy described below. The electrical system consisting of electrical devices and wiring is located in/on the premises at: 1 Birch Lane Rye Brook, New York 10573 The Basement Living Room and Family Room were inspected in accordance with the NYS and NFPA 70-2014 and the detail of the installation, as set forth below, was found to be in compliance on the 16th day of September 2019. Name Quantity Rating Circuit Type Receptacles 24 Switches 16 Luminaires 30 Single Pole Arc Fault 04 20 Amp ,J.,JIJ Officer: Frank J. Farina This certificate may not be altered in any way and is validated only by the presence of a seal at the location indicated.This certificate is valid for work performed on the date of inspection only. S&J Builders INC. 8 Grand Canyon lane ' Coram New York „727 �3 R 1-631-746-6363NY 11771 FULL INTERIOR s.j.btAdersl2l2@gffmO.com RENOVATION MTO Invoice INVO400 Jod And Howard Lavitt 03/28/2019 1 Birch Lane Due on receipt Rye Brooke NY, 10573 Rye Brook NY DESCRIPTIONQTY RATE AMOUNTi Do -Allion $3,150.00 $3,150-00 -Remove all doors with hinges -remove carpet throughout -remove all drop ceiling(ceiling tiles) -remove all tiles from bathroom(keeping all plumbing the same) Salvage(toilet,glass shower door and panel) -Properly remove all demolition debris from property Doors 7 $300.00 SZ100.00 Supply and install new doors single panel. With new hinges and locks C.eftV $4,800-00 $4)[M.00 Supply and install new sheet rock 5/8" Throughout ceiling. Plaster tape sand and prime ready for paint. Floor irrstalati r $5,800.00 $5)[M.00 Supply and install new vinyl flooring throughout. Supply and install new base board throughout Bath $3,430.00 $3,430.00 Install new tiles Walls ceiling and floors Paint lhr+o Mhowa $5,800.00 $5,800.00 Paint -ceiling -walls - doors and trim Page 1 of 2 Tcrtai 925,080.00 Balance Due S25,080M Rpx 03/18noig Page 2 of 2 6R J v l�L� �t,vv1� 40" annuumaW VILLAGE OF RYE BROOK MAYOR 938 King Street,Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A.Klein (914)939-0668 Christopher J.Bradbury w«,Nti'.ryeb rook.org TRUSTEES BUILDING & FIRE INSPECTOR Susan R.Epstein Michael J. Izzo Stephanie J. Fischer David M.Heiser Salvatore W.Morlino October 6,2022 Dear Rye Brook Building Permittee, It has come to the attention of the Building Department that your Building Permit has not been closed out in accordance with Village Code and is now expired.All Building Permits have a twelve (12) month lifespan starting from the date of issuance,and the permit expiration date is noted on the front of the permit. Please note that there is a non-waivable Expired Permit Fee of$500.00 now due in connection with your expired permit.Once payment is received,your permit will be reinstated for a period of six(6)months. Please be advised that it is a violation of Village Code to fail to close out a permit,and that a court summons could be issued,and fines may be imposed on the permit holder and/or property owner for failure to apply for and obtain a Certificate of Occupancy(C/O) or Certificate of Compliance(C/C),in accordance with Village Code section 250-10A. Please note that Temporary C/Os&C/Cs are available in accordance with Village Code section 250-10B should you require more time to perform whatever work remains in order to complete your project. Thank you for your attention in this matter,and please feel free to contact this office should you require any further information. 0��- Nfichaelj. Izzo Building&Fire Inspector mizzo_.rvebrook.org /to cc: Steven E. Fews,Assistant Building Inspector Tara A. Orlando,Planning&Zoning Secretary Laura Petersen,Office Assistant 0 ti LO 1116 - LLJ O ` QI cn O u 0. N a: Fi� o b � 44 4 v � z � a o ►. .5. 2 x � a M n Y _o � Z OC SEW yp LLA Y LAJ V " Q _j pG c \ Y M C Building Permit Check List&Zoning Analysis Address: 2-�u wy��— SBL: 13 S • 'L1 Zone: - i s­ Use: Const.Type: Other. Submittal Date: Revisions Submittal Dates: Applicant: L AV .YC- Nature of Work: L Tz�yc l Sl-c NG 11 N S N�P,a Reviews:ZBA 19 PB: BOT: Other. OK ( ( ) FEES:Filing- BP: r, C/O: Legalization: ( ) (yAPP: Dated ✓ Notarized ✓SBL Trios I.D. Cross Connection H.O.A.- Scenic Roads: Steep Slopes: Wetlands: Storm Water Review: Street Opening. ( ) ( ) ENVIRO:Long. Short: Fees: N/A: ( ) ( ) SITE PLAN:Topo: Site Protection S/W Mgmt: Tree Plan: Other. ( ) ( ),,SURVEY:Dated Current: Archival• Sealed Unacceptable: ( � ( ) PLANS:Dar;Stamped: ✓ Sealed Copies: Electronic Other. J License:_V Workers Comp: Lability Comp.Waiver. Other. ( ) ( ) CODE 753#: Dated N/A: (•� ( ) HUGH-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. ( ) ( ) H.V.A.C.: Plans: Permit: N/A Other. ( ) ( ) FUEL TANK:Plans: Permit: Fuel Type: Other. ( ) ( ) 20I7 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: APPROVED REQUIRED EXL4TING PROPOSED NOTES J UN - 6 2019 Area: Circle: Fir Front: Front: Sides: Rear. Main Cov Accs.Cov: Ft.H Sb: Sd.H Sb: GFA: Tot.in: Ft.I Par Height/Stories: notes: lip 0 EWMI ,gip , • � ,0 .• v • N • �' N vks-I MORN �# �,1�11111111�1 1� 1j11//11111 4 ,\f�11111/11i1� ' v ,:.11111//111b t1111111111 '' • t •1-'1,1 ,► 1 1111�11 v 11�14�.is,.., �� „l7 �a ess: 11 11':e?�:x 1 :'t...;1►1�1 • •r ,:r- C r ] / Y 0 «O)R •�� a Lei N fa1 •� h U 4..r CD... t�'+•• s <(o)> p N O CVO ' c " w U CA LLI UD a e 00 _ Q '0 !' COMO y � OCo mod. O ' „ L V co t / Slllllt. t Ijj1t1 z 11/lllllt 11111�/�1 zs'. .`%111 NI»i1r+t+"�fs'�t (�;?(�.�Fy 11/11/ j■��j 11/11111 �1/1/111�. IIIINIt �11111/t, t •��$ '�€?. .A`. ♦�� ft� A 'f ��• n,�AIAP' ♦• '"s.Ai � 1 N `eIAP' .j� 11111 V i� f -ear ' �1�1111..•;.f`•iA�>i .1'•� p "1�.1`"�'� Lq ,�\%Q�f 'tt n• b� tt ��' .� ^ t A J'�' �� ^ `q ''� Y.iCJ+'-Vt A. .•]1Gp.. ''L .�`t, .1 ,�7p'. .� t i-.,,ic'�.� .�:sl]..•+ 1 v4v v v V,.YJv I,Y '•�v •.tvf• AC"R" CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 06/08/2019 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 have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Cotten Coverage Insurance NAME: 530 Horseblock Road A C.N 6316984776 ac No:6316986091 P.0.Box 557 E-MAIL ADDRESS: Farmingville,NY 11738 INSURERS AFFORDING COVERAGE NAIL• INSURER A: American European Insurance Company 23337 INSURED S&J Builders Inc INSURER B 8 Grand Canyon Lane Coram,NY 11727 INSURER c: INSURER D: INSURER E: INSURER F: 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 ADD LiSUBR POLICY EFF POLICY EXP L TYPE OF INSURANCE INPOLICY NUMBER MM/DD YY (MWDD/YYYYI LIMITS A COMMERCIAL GENERAL LIABILITY Y SKP5000692 04/09/2019 4/09/2020 EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE V OCCUR PR MISES Ea l S 100,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY❑ PRO- LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT(Ea accident) $ ANY AUTO BODILY INJURY(Per person) : OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) $ S UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N TATUTE ER ANY PROP RIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED4 ❑ N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 'DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more specs is required) Certificate holder and Jodi and Howard Lavitt 1 Birch Lane Rye,Brooke NY 10573 are listed as additional insureds as required by written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN The Village of Rye Brook ACCORDANCE WITH THE POLICY PROVISIONS. 938 King Street Rye Brook,NY 10573 AUTHORIZED REPRESENTATIVE 4 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD New York State Insurance Fund Workers'Compensation & Disability,Benefits Specialists Since 1914 8 CORPORATE CENTER DR,3RD FLR,MELVILLE,NEW YORK 11747-3129 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE 0 f' 0 ^A A^^^ 810776856 MANSI INTERNATIONAL LLC 43-05 31 ST AVE a 2 ASTORIA NY 11103 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER MANSIBKG@HOTMAIL.COM S&J BUILDERS INC THE VILLAGE OF RYE BROOK 8 GRAND CANYON LANE 938 KING STREET CORAM NY 11727 RYE BROOK NY 10573 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE 12445 567-7 12493 05/20/2019 TO 05/20/2020 6/10/2019 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2445 567-7, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY, IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY, INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTPS://WWW.NYSIF.COM/CERT/CERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THIS POLICY DOES NOT COVER CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED BY THE OFFICERS OF THE INSURED CORPORATION. PRESIDENT JOSE BECERRA S&J BUILDERS INC (ONE PERSON CORP) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. NEW YORK STATE INSURANCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 142053888 U-26.3