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HomeMy WebLinkAboutSP19-003PI imi T - �OATE• q EXP: SECTION RLOCK LOT TYPE OF WORK JOB LOCATION ! �R�rwl ` '! �mllvm&ZO• • iNSPECTlO R CORD DATE INSP FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING [] RGH PLUMBING GAS SPRINKLER ELECTRIC Low -VOLT p ALARM Q AS BUILT Q FINAL 1�� ba. Lev 419 31%� R,ncOO 0I Q67-0457 EP 0jyEle,G�i-ric eR APPROVALS f'P"2019 �f47,1 IL ime� QyE DR 4 C�op WJ� . 19 VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914) 939-0668 Christopher J. Bradbury www.ryebrook.org TRUSTEES BUILDING& FIRE INSPECTOR Susan R. Epstein Steven E. Fews Stephanie J. Fischer David M. Heiser Salvatore W. Morlino CERTIFICATE OF COMPLIANCE June 16,2023 Washington Park Plaza Associates C/o Martha Levy 253 South Ridge Street Rye Brook,New York 10573 Re: 253 South Ridge Street, Rye Brook,New York 10573 Parcel ID#: 141.35-2-51 Sign Permit#19-003 issued on 7/2/2019 for New Sign This certifies that the new sign;CVS,installed under the above captioned permit has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to p 5[ BUILDING DEPARTMENT PERMIT# WS MAY — 8 2023 VILLAGE OF RYE BROOK ISSUED: — VILLAGE OF RYE BROOK 38 KING STREET,RYE BROOK,NEW YORK 10573 DATE: --a3 BUILDING DEPARTMENT_ (914)939-0668 FEE: & lo/0 PAID APPLICATION FOR CERTIFICATE OF OCCUPANCY,CERTIFICATE OF COMPLIANCE, AND CERTIFICATION OF FINAL COSTS ttttttttitttt•itittit•ttittitttt►•titttt•t•♦ti ifilttti•ftttit♦•ittt►•t/it ttltttittttttttttftttttttttttf ttt tttttiiii ittttti/t♦ Address: 253 South Ridge Street- Washington Park Plaza Occupancy/Use: Commercial Parcel ID#: 141 -2-51 Zone: 0)6-1 S Owner: Washington Park Plaza Associates/Martha Lew Address: P.E./R.A.or Contractor: CAD Signs Address: 169 Lodi St. Hackensack NJ 07061 Person in responsible charge: Alejandro Galeano Address: 169 Lodi St.Hackensack NJ 07061 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 YORK,COUNTY OF WESTCHESTER as: Alejandro Galeano being duly sworn,deposes and says that he/she resides at 169 Lodi St. in Hackensack NJ 07061 ,in the County of Bergen in the State of NJ that 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: 1,050.00 > for the construction or alteration of: Pylon Face Replacement 3.19 sgft Led illuminated channel letters an logo on raceway 23.83 sqft Deponent further states that he/she has examined the approved plans of the structuretwork 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-IO.A.of the Code of the Village of Rye Brook. •, Sworn to before me this Sworn to before me this Yh day of , 2023 day of i ,20 a 3 Signature of Property Owner ture of Applicant DD /ri � JQ�1�� Print N f['ropem Ou*rer Print Nam rrf Applics)//1 wv '� yt E Or M RIA MU St ATE0, 1AARi ti,NIZ . '•4, NOTARY �SLIC OF NEW JERSEY ;eT N6iARv t�t?�tll Of EW JERSEY "`� COMMISSION a 50116843 ti ue. ` &i0(ki165iON,a S0116843 tiFw'EpSE MYCCNNMISSRA XPIRES11/13/2024 Fw'Et�� MYCOMMISSIONEXPIRESII/131X24 �yE DRcbl a �m • 1982 BUILDING DEPARTMENT 9-BlIrILDINGINSPECTOR ❑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 : f v I .__ �CQ DATE: � I t 1 1-2 C� �1 PERMIT# .mil �C `` , ISSUED: $ CT: BLOCK: LOT: LOCATION: C Y f7-A` �` OCCUPANCY: ❑ Violation Noted THE WORK IS... El PASSED ❑ FAILED REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ Natural Gas U�j�i1 t c�L{��__szn. ❑ L.P. Gas ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FP AL PLUMBING IfOSS CONNECTION r FINAL ❑ OTHER • �`i�`i�i1��l�l�l�iii�i�l���i��'i�ii�l�r��'i��"i�`i�'i�il�il�l�l��i�ii�il�i �l��l�il�r�i���l�l�i r-I N N 01 o N �C ;: F �= Z � a 1 > x f ° F J S - J Y�i� .I f� •-• � z � M � �' Z < G• 00 co ON w � o a, (W.-O x cr T 3 � i G. Z CL rA �I a. Z w _ UP) �r ��� D EC ENE BUIL011 6__�E�'AR MENT AUG 2 2�19 VILLAIGE OF RYE "OK 938 KING ET RYE B ,NY 10573 VILLAGE OF RYE BROOK (914)9 939-5801 BUILDING DEPARTMENT w . or ELECTRICAL PERMIT APPLICATION Westchester County Master Electricians License Required FOR OFFICE USE ONLY #: f - ��C EP Approval Date: AUG 2 1 2019 Permit Fee: $ i5opcLl Approval Signature: Other: Disapproved: (fees are non-refundable) ****************** *** *************************************************************************** Application dated, is hereby made to the Building Inspector of the Village of Rye Brook NY, for the issuance of a Permit to install an or rei4iove 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.2 1.Address: �� � / CJr /`�� rim �� SBL: 14[ ` 5: 69 "".�I Zone:(),EE-5 2.Property Owner: Address: /,Z,/`�— > S f� Phone#: / Cell#: QQ/91 I z4- �I Q-3 I VJCGbmail: 3.Master Electrician: Address: � z? Lic.#:f"'X' Phone#: � Z2 �Ce11#: 54n' email: Company Name: h�&4Y Address: 14_ 4.Proposed Electrical Work/Fixture Count: ********************************************************************************************************* LSTATE OF NEW 1(q ,COUNTY OF WESTCHESTER ) as: ng duly sworn,deposes and states that he/she is the applicant above named,and does further (print name of individual signing as the applicant) y��i state that(s)he is the legal owner of the property to which this application pertains,or that(s)he is the 11VI —1 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 to b ore e i 2U 7-W day of 20 day of ,20�_ Signature of Property Owner Si ature of Applicant Print Name of Property Owner Print �Name of Applicant TQDC)j 'MrF uUA6F Notary Public N46 r icc,'State of New York Reg.No.01W06371198 } Qualified in Dutchess County Commission Expires 02/20/2022 3/21/19 Westchester Rockland Electrical Inspection Services, Inc. Phone: 914-347-3595 DQ NOT WRITE HERE-FOR OFFICE USE ONLY 43 North Lawn Avenue Fax: 914-347-3596 Elmsford, NY 10523 - BUILDING PERMIT NO. TEMP N DATE CITY OR VILLAGE ZIP CODE TOWNSHIP y/ // COUNTY STREET AND NO.OR ROAD //-7 � �i �_ y- POLE NUMBER BETWEEN WHAT TWO CROSS STREETS IS PREMISES LOCATED? SECTION' BLOCK LOT OCCUPANT'S NAME BUILDING OCCUPANCY OWNER'S NAME AND ADDRESS _ �fj_ ��.,�- V HOME TELEPHONE NUMBER [/1 CURRENT SUPPLIED BY FROM THEIR OFFICE WORK TELEPHONE NUMBER LIST BELOW ALL EQUIPMENT WHICH YOU INSTALLED NUMBER OF OUTLETS NO.OF FIXTURES& MOTORS HEATERS OFFICE USE LOCATION LAMP RECEPTACLES ONLY SIDEWALL SWITCH INCADE FLUORE NO. H.P.EACH NO. WATTS N OUTSIDE BASEMENT 1'FL AUG 2 0 2019 2'°FL. 3' FL. ING DE ARTMENT REMARKS:LIST OTHER ELECTRICAL DEVICES NOT SET FORTH ABOVE: 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 AS PROVIDED BY THE APPLICANT.THE APPLICANT DECLARES THAT THERE IS NO OPEN APPLICATIONS FOR THE ABOVE WITH ANY OTHER INSPECTION COMPANY.WREIS,INC. IS NOT LISTING,LABELING,UNDERWRITING OR CERTIFYING ANY EQUIPMENT, MATERIALS OR DEVICES WHICH ARE PERFORMED BY OTHER CERTIFIED TESTING AGENCIES OR INSPECTION COMPANIES.THE APPLICANT,OWNER,OR AUTHORIZED AGENT AGREES TO ALL THE ABOVE TERMS AND CONDITIONS AS SET FORTH FOR THE APPLICATION. SIZE OF SERVICE FEEDERS CHARACTER OF WORK NEW G ADDITIONAL L7 EXPOSED❑ CONCEALED❑ MUST ENTER APPLICANTS IDENTIFICATION NUMBER C SERVICE ENTERS BUILDING OVERHEAD Ll UNDERGROUND ULLA I '^ > AVOID DELAYS BY GIVING FULL AND ACCURATE INFORMATION.ALL SPACE MUST BE FILLED IN OR APPLICATION MAY BE RETURNE/D. NAME OF COMPANY DATE OF CATI SIGNATWtCOF G• TELEPHONE NO. CITY OR POST OFFICE /�/t > -Z/ LICENSE NO.WHEN APPLICABLE i NESTCNESTEt IIOCKL�NO EIECTRICAL INSPECTIOM WRE111SERVICES.INC. BY THIS CERTIFICATE OF COMPLIANCE THE Westchester Rockland Electrical Inspection Services 43 North Lawn Ave, Elmsford, NY 10523 914-347-3595 (Office) 1 914-347-3596 (Fax) CERTIFIES THAT Upon the application of: Upon premises owned by: Energy Electric Washington Park Plaza Assoc. / N 58 Route 292 Holmes NY 12531 Located at: 253 S Ridge St, Rye Brook, NY 10573 Certificate Number: 641677 Section: 141.35 Block: 2 Lot: 51 BDC: Permit Number: EP:19-221 BP:19-003 A visual inspection of the electrical system at this premise described as a Commercial occupancy,wherein the premises electrical system consisting of electrical devices and wiring, described below, located in/on the premises at: 253 S Ridge St, Rye Brook, NY 10573 ❑Basement ❑1st Floor ❑2nd Floor ❑3rd Floor ❑Garage ❑Attic ❑X Outside Other: Inspection was conducted in accordance with the NYS and NFPA 70-2017 International Electrical Code and detail of the installation, as set forth below, was found to be in compliance therewith on 11/11/2019 Name Quantity Rating Circuit Type Sign 1 Outdoor Disconnect 1 This Certificate has been approved by Westchester Rockland Electrical Inspection Services. This certificate may not be altered in any way. This certificate is valid for work performed before date of inspection only. Building Permit Check List &Zoning Analysis OB & C ONLY Address: Z S SBL l ( • 3 5 Z - -S l Zone: 03 S Use: Const.Type: l Other. Submittal Date: 57121 15 Revisions Submittal Dates: Applicant: yV X 14-c fJ<W ry (-I- �..A-?A Nature of Work. �IML,-) S (4 N ,A`r CCU ,S Reviews:ZBA 2019 PB: BP: Other. VE OK �n ( ) FEES:Filing. 3-V 4�BP: � 1V 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 Short 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. ( } (-)"License: Workers Comp: ✓ Liability: Comp.Waiver. Other. ( ) ( ) Code 7S3#: 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.: Mans: Permit N/A Other. ( ) ( ) FUEL TANK Plans: Permit: FUEL TYPE: Other: ( ) ( ) 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. _ (�)��n(D) Other. ( 7�mtg.date: S i S 107 approval 6 notes: ( )ZBA mtg.date: approval:- notes: ( )PB mtg.date: approval: -notes: REQUIRED EXISTING PROPOSED NOTES APPROVED Area: .._.__ JUN 2 7 71110 Circle: T�� Frontage _ Front: Front: Sides: Rear. F.A.R.: en Space He�1u: Stories: notes: BUILDtNf,-0 ARTMENT p GG VILL E OF RYE BROOK 938 KING ET RYE BR661k, NY 10573 EMAY2019 (914)9 99 39-5801 or2 VILLAGE OF RYE BROOK I _ I BUILDING DEPARTMENT ARCHITECTURAL REVIEW BOARD CHECK LIST FOR APPLICANTS This form must be completed and signed by the applicant of record and a copy shall be submitted to the Building Department prior to attending the ARB meeting. Applicants failing to submit a copy of this check list will be removed from the ARB agenda. Job Address: 7 cj > Ae- -S Date of Submission: Parcel ID#: Zone: Proposed Improvement(Describe in detail): APPLICANT CHECK LIST: 1/IS41/ MUST BE COMPLETED BY THE APPLICANT ( (05e-1 oL C/&612e/ZI��L5 The following items must be submitted to the Building �,,lCCtva-t., // _9� I\9 2 05�I vx Department by the applicant-no exceptions. 6WI4 oln l. Completed Application 1,_Z 2. Two(2)sets of sealed plans. (one lull size (maximum Property Owner: A,114La, Lej.a allowable plan size=36"x 42") and one I 1"xl7") Address: �,� 1/e- �1 � 4 �(� yy 10,t0 3. (A Two(2)copies of the property survey. f�,��(vt —� 4. Two(2)copies of the proposed site plan. Phone# !7 jq — q I q - 3 ! �� 5. One electronic/disc copy of the complete Applicant asp pearing before the Board: application materials. 6. �) Filing Fee. 7. )Any supporting documentation. 8. ( )HOA approval letter. (ifapplicable) Address: 9. ( )Photographs. Phone# 10.( )Samples of finishes/color chart. (a sample board or Architect/Engineer: model may be presented the night of the meeting) Phone# By signature below, the owner/applicant acknowledges that he/she has read the complete Building Permit Instructions&Procedures,and that their application is complete in all respects.The Board of Review reserves the right to refuse to hear any application not meeting the requirements contained herein. A� �� I?lz , /j, Sworn to before me this Sworn to before me this z L day of , 201f day of , 20—d Signature 6fPr rlyOwner Si of of Applicant 9 .tile}AAA "lE✓�s. /f Ash 6 11� 6 Print ame of Property ner Pri N me of Applican III No AN S. MARIN Notary VAN S. MARIN NOTARY PUBLIC NOTARY PUBLIC STATE OF NEW JERSEY STATE OF NEW JERSEY ID#2411344 ID#2411344 MY COMMISSION EXPIRES AUG. 11,2021 MY COMMISSION EXPIRES AUG. 11,2021 '`lfayI� � ay ll 3/21/19 VILLAGE OF RYE BROOK BUILDING DEPARTMENT 938 KING STREET, RYE BROOK,NY 10573 (T) 939-0668 (F) 939-5801 ARCHITECTURAL REVIEW BOARD Wednesday, June 19, 2019 NAME&LOCATION TYPE OF APPLICATION MOTION SECOND APPROVED REJECTED APPL.# 3 Hillspoint Lane Amend Prior Fence Consent 4730 (Cohen) Application Change From Agenda Vinyl to Wood 14 Arlington PI Replace Existing Wood Consent 4731 (Vespia) Decking With Azek Material Agenda 25 Pine Ridge Rd Redo& Straighten Existing Consent 4732 (Jensen/Perez) Contoured Front Walk Agenda wBlue Stone 14 Lawridge Dr Amendment Application to Consent 4733 (Kaplan) Restore Existing On Grade Agenda Patio 14 Lawridge Drive Window Change Double Consent 4734 (Kaplan) Hung To Casement Agenda 41 Rock Ridge Dr (2) Rear Window Consent 4735 (Stein) Replacements Agenda 64 Talcott Rd(Pinto) New Door @ Basement Consent 4736 Agenda 11 Carlton Lane Basement Window And Consent 4737 (Marconi) Door Change Agenda 33 Whittemore Place 4Ft Black Chain Link Fence 4738 (Reilly) (Village Easement) 1002 King St Amend Prior Approval To 4739 (Schueller) Include Outdoor Kitchen @ Pavilion 20 Old Orchard Road Amendment To Prior 4740 (Scott Tillison LLC) Approval (53 S. Ridge St Update Signs @ CVS 4741 CVS �� ML NM MR f SE JM SF AC MI JB I§Bonwit Rd 1 st&2nd Story Additions. 4742 (Kulekofsky) New Front Porch&New Rear Deck 109 Country Ridge (2) 1 Story Additions& 4743 Dr(Marcoccia) Portico 8 Old Oak Rd Rear 1 Story Addition 4744 (Bober) 86 Windsor Road Remove Window From Side 4745 (Benoit) Elevation 2 Wilton Road Amendment to Prior 4746 (Chen) Approval 48 Valley Terrace 2nd Story Addition 4747 (Ryan) 4 Concord Place New Deck, Masonry Patio 4748 (Sheer) W/Fire Pit ML NM MR SE JM SF AC MI JB Policy Number: Date Entered: 9/25/2019 ACOR" CERTIFICATE OF LIABILITY INSURANCE DATE 11"DDIYYYY) 9/25r019 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(iea) 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 statemert on this certificate does not confer rights to the certificate holder in lieu of such endorsement(,). PRODUCER Co WT ACT Michael llg NAME: Michael fig PHONE 8 Bartics Corner Rd Arc No Eat:(908)751-5922 IArc,Me) (866)619-5712 ADDRESS:shannon@ff-nj.com Suite 23 INSURIERM AFFORDING COVERAGE NAIL 0 Flemington.NJ 08822 INSURER A•FAR6I FAMILY CASUALTY INSURANCE 13903 INSURED Signs CAD Corp dba CAD Signs INSURER 0,United Farm Family Casualty Insurance 29963 INSURER C 169 Lodi St INSURER D Hackensack.NJ 07601 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, LTR TYPE Or INSURANCE INSO WVD POLICY NUM ER JMsaDONYYYlMMI DD/YYW LIMITS A COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1.000,000 cLP.IMs-MADE ®xcuR 2901X6162 10a4/2019 i02412020 PREMISES EaomXrerCe s 100,000 MED EXP(Any are parson) S 5,000 PERSONAL 8 ADV INJURY S 1,000 000 GENL AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE s 2,000,000 POLICY JECT LOC PRODUCTS-COMPIOPAGG S 2,000,000 OTHER $ AUTOMD BILE LIABILITY aaldent I.000,000 R AW AUTO T 901('3;01 10/24,2019 1012412020 BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) S HIRED NON-OWNED 'PROPEMY DAMAGE AUTOS ONLY AUTOS ONLY Per accident) S S UMeREluLIAR OCCUR EACH OCCURRENCE s 5,000,000 EXCESS LIAR ri CLAIMS-MADE 290I E2418 1012.11.2019 10/24/2020 AGGREGATE S 5,000,000 DE RETENTION S 10,000 $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN STATUTE R K ANY PROP RIETORIPARTNER/EXECUT VE N f A - 10.'.1:OIY IUl2Y2020 E.L EACH ACCIDENT $ 1,000,000 A OFFICERIMEMBER EXCLUDED? _902 W6718 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S 1.000,000 If yes describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (AC OR 101,Additional Remarl,s Schedule,may be attached d more space is requ ued) CERTIFICATE HOLDER CANCELLATION Village of Rye Brook 938 King Street SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Rye Brook,NY 10573 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORAT10N. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Produced using Forms 3oss Plus software.www.FormsBoss.com.Impressive Publishing,LLC 800-208-1977 vORK Workers' CERTIFICATE OF STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1 a. Legal Name&Address of Insured(use street address only) 1 b. Business Telephone Number of Insured SIGNS CAD CORP DBA CAD SIGNS 201-267-0457 169 LODI ST 1c.NYS Unemployment Insurance Employer Registration Number of HACKENSACK, NJ 07601 Insured Work Location of Insured(Only required if coverage is specifically limited to 1d. Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e.,a Wrap-Up Policy) Number 27-0186720 2.Name and Address of Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) FARM FAMILY CASUALTY INSURANCE VILLAGE OF RYE BROOK 3b.Policy Number of Entity Listed in Box"1 a" 938 KING STREET RYE BROOK, NY 10573 2902W6718 3c. Policy effective period 10/24/2018 to 10124/2019 3d.The Proprietor,Partners or Executive Officers are ✓❑ 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 '1 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"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 MICHAEL ILG (Print name of authorized representative or licensed agent of insurance carrier) Approved by 4/18/2019 (Signature) (Date) Title: CAPTIVE AGENT FOR FARM FAMILY Telephone Number of authorized representative or licensed agent of insurance carrier 908-751-5922 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