HomeMy WebLinkAboutBP19-134PERMIT #
SECTION r I
TYPE OF WORK
JOB LOCATION .
INSP
FOOTING
FOUNDATION
FRAMING
RGH FRAMING
INSULATION
PLUMBING C3
RGH PLUMBING,
GAS
SPRINKLER O
ELECTRIC
LOW VOLT 0
ALARM 0
AS BUILT
FINAL
0
ZBA
OTI�ER
VILLAGE OFE BROOK
WESTCHESTER COU , NEW YORK
NO: 22-147
Certificate of Occupancy
This is to certify that
of, R)16 / V y having duly filed an application on
20��requesting a Certificate of Occupancy for the premises known as,
/y— &fir)0-k)n P10-6-e , Rye Brook,NY, located in a -/0 Zoning
District and shown on the most current Tax Map as Section: /�, Block: Lot:
and having f illly complied with the requirements of the Building Code and the Zoning Ordinance under Building
Permit No. / , issued 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: _ / 0�'fzm; Construction: EP
for the following purposes: P p I 6C-C
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 heig t sha be mad the building be moved from one location
to another until a permit to accomplish such change has b n t ' Inspector.
1 I 1011
Building Inspector,Village of Rye Brook: Date:
BUILDIN9-DEPARTMENT For office use only
VILLAGE OF RYE Bilttil)K ISSUED: — -
938 KING STREET,RYE BROOK,NEW YORK 10573 DATE: — -aC GLJ
(914)939-06 9�939-5801 FEE: PAID
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
sssssssssss•sssas•ssssssrssssssssrssrssrsss••ssssssss•sss•sss•ssss•sssssasssssasssssssssssassssssssssssssassssresssssssssssrs
Address: 14 Arlington Place n
Occupancy/Use: One Family Parcel ID#: 135.44-1-41 Zone:
Owner: Hope B. Vespia Address: 14 Arlington Place
P.E./R.A.or Contractor: Address:
Person in responsible charge: Steven J. Vespia Address: 14 Arlington Place
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:
Steven J. Vespia being duly sworn,deposes and says that he/she resides at 14 Arlington Place
Print Name of Applicant) (No.and Street)
in Rye Brook ,in the County of Westchester in the State of NY that
(CitYrrowrJ Village)
he/she has supervised the work at the location indicated above,and that the actual total cost ofthe 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:S 27,000.00
for the construction or alteration of. Replace Wood Decking with AZEK
Deponent fisher 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 ' Sworn to before me this J
day of () day of 0 , 20_d)_
e /►y/
Signature of Poilperty Owner Signature of Applicant
Hope B. Vespia
Steven J. Vespia
Prittt Name of owner tRAYMOND L.SCULKY Print Name of Applicant
Notary Public,State of New York Ar,�
Nay P Registration No.OISC5084250
Qualified In Westchester County
Terra Expires September 2i�V I
QyE BRC��,
O� y�
1932 BUILDING DEPARTMENT
❑BUILDING INSPECTOR
SSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK
i ❑CODE ENFORCEMENT OFFICER 938 KING STREET • RYE BROOK,NY 10573
(914) 939-0668 FAx (914) 939-5801
www.tyebrook.org
- - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - -
ADDRESS :— DATE: �I �t3l���!
PERMIT# ' ` ISSUED: , I^�SECT: BLOCK: LOT:
LOCATION: � * ` ` -� ( I(,- �} OCCUPANCY: Z
❑ 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
❑,i FINAL
/b OTHER
0
Building Permit Check List&Zoning Analysis
Address: P"�—W!N �{ C— SBL•
Zone: ::P- Use: Const.Type: Other.
Submittal Date: (o CSk!� Revisions Submittal Dates:
Applicant: v F
Nature of Work: : ' iJ z -C-12t"4 w A z F h
Reviews:ZBA 2019 PB: BOT: Other.
NEED OK
( ) FEES:Filing. - o BP: I C/O: Legalization:
( ) (�APP: Dated: Notarized: SBL Truss I.D. Cross Connection: H.O.A.:
( ) ( ) Scenic Roads: Steep Slopes: Wetlands: Storm Water Review: Street Opening:
( ) ( ) ENVIRO:Long. Shore 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: Electronic Other.
(vY ( ) License: Workers Comp: Liability Comp.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.
( ) ( ) 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.
mtg.date: lri l approval:- 7 0 notes:
( )ZBA mtg.date: approval: notes:
( )PB mtg.date: approval:- notes:
REQUIRED EXISTING PROPOSED NOTES APPROVED
Area w,,_?7
Circle Vate:
Frone
Front:
Front:
Sides:
Rear.
Main Cor.
Accs.Cor
Ft.H Sb:
Sd.H Sb:
GFA:
Tot.Imp:
Ft.Im
Park'
Height/Stories:
notes:
BUILDIN R ARTMENT D S Q,`V I�
VILLAGE OF RY&OROOK V
938 KING STET RYE BR66Y NY 10573 JUN 0 5 2019 DD
(914)93-66 9 `939-5801
VILLAGE OF RYE BROOK
wVv:yvroo r 2BUILDING 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: �r �tHn G Date of Submission:
Parcel ID#: _ Zone:
Proposed Improvement(Describe in detail): APPLICANT CHECK LIST:
MUST BE COMPLETED BY THE APPLICANT
The following items must be submitted to the Building
W /'/`j A Z jE K, �eG 1(j rl q Depart ent by the applicant-no exceptions.
1. Completed Application
2. ( )Two(2)sets of sealed plans. (one full size(maximum
Property Owner: /�IPA— V �S�t allowable plan size=36"x 42")and one 11"x17")
Address: I y � .ln� �G 3. ( Two(2)copies of the property survey.
t!►14 / q 4. ( )Two(2)copies of the proposed site plan.
Phone# WV- 13 � — y80 / 5. ( One electronic/disc copy of the complete
Applicant appearing before the Board: pplication materials.
6. Filing Fee.
S�-ttJ�y1 /eS,O/� 7. ( Any supporting documentation.
Address: g ( ) OA approval letter. (tf applicable)
9. (photographs.
Phone# �1�7 — �3 �/��/ 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 army/application not meeting the requirements contained herein.
Sworn to befor a this 7` Sworn to before me this
day of , 20� day off n 'e- 20 I °�
Signature of Pro Owner Sii nattue of Appli t
Print ama4f Property Owner Print Name of Applicant
. `\ RAYMOND L.SCULKY
Notary Public ' NaboyMUc,State O
Registration No. 01SC5084251"
J""MFIL ROAF a HI Qualified In Westchester Count,:
Noary Publfo,state of New York NO.otRls24rn Term Expires Sept r 2
°a\
Cuolllted In Westchester Ccutgy
Term Expires June 8,2019 3/21/19
e
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 I APPROVED REJECTED APPL.0
4730
3 Hillspoint Lane Amend Prior Fence Consent
g -T
(Cohen) Application Chane From Agenda
Vinyl to Wood
14 Arlington P1 Replace Existing Wood Consent 4731
(Vespia) Decking With Azek Material Agenda
25 Pine Ridge Rd Redo& Straighten Existing Consent �J 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
253 S. Ridge St Update Signs @ CVS 4741
(CVS)
ML NM
MR SE
JM SF
AC MI
JB
► 1
19 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
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Check List For Release of Building Permits
Address: 1+ &hoo4oc) Plnra,
Owner/Applicant: -prx�egz�.
Phone Ws: 91-4-5R4- -o�581
Dates Attempted To Contact Owner/ Applicant:
Comments: �. ��/� �
Comments:
Comments:
NEED:
(V' Building Permit Fee $ i
( ) UFPO #
( ) C Home Improvement License
( ability
( orkers Comp. / 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
ADIRONDACK Policy Number:
INSURANCE EXCHANGE' Y
PO Box 3199•Winston Salem,NC 27102-3199 2003894157
Named Insured:
STEVEN J VESPIA
STEVEN J VESPIA HOPE B VESPIA
HOPE B VESPIA stevevespia@optonline.net
14 Arlington PI Policy Period: 12:01 AM
Rye Brook, NY 10573-1711 6/1012019-6/10/2020
Date of Notice: 5/6/2019
Policy Underwritten By:
ADIRONDACK INSURANCE EXCHANGE
24 Hour Claim Reporting: 1-877-629-8003
For Policy Information:1-877-629-8003
www.aie-ny.com
9009502
Borrelli Partners Insurance,Llc
287 Bowman Ave FI 4
Purchase NY 10577
(914)939-7900
ONECHOICE CUSTOM-PAC POLICY DECLARATIONS
Transaction Payment Plan
RENEWAL DIRECT BILL-4-PAY
Dear Policyholder,
BORRELLI PARTNERS INSURANCE, LLC and ADIRONDACK INSURANCE EXCHANGE are pleased to present you with your
OneChoice package Renewal insurance policy.
In the event of a loss,call our toll-free number 1-877-629-8003 for 24-hour claim reporting.Our dedicated professionals are ready to
help 24 hours a day,seven days a week.
Thank you for letting us be of service and if you have any questions,please contact Borrelli Partners Insurance,Llc at(914)939-7900.
MESSAGES
PLEASE REFER TO THE"IMPORTANT NOTICES"SECTION OF THIS POLICY FOR IMPORTANT INFORMATION
CONCERNING THIS POLICY.
Your Coverage C Limit has been increased at no additional charge.
To keep pace with rising replacement costs,your property coverage limits have been upgraded.
TOTAL SURCHARGE AMOUNT
NONE
Adirondack Insurance Exchange uses MuellerCalc,based on copyrighted construction estimating from Craftsman Book Company,and
Marshall&Swift/Boeckh Residential Component Technology methodology for estimating the replacement cost of a dwelling.
SH DC 02(01 04) -1-
Adirondack Insurance Member Benefits
Below are just a few of the many benefits available to you as an Adirondack Insurance member.Please visit www.aie-ny.com
for more information. You may also refer to your membership materials or contact your agent.
• Identity Theft 911 Resolution Service
• Credit Monitoring
• Document Recovery Service
• Roadside Assistance
• On Line Auto&Home maintenance Checklists
• On Line Financial Tools&Calculators
• And More!
POLICY PREMIUM SUMMARY
Automobile Premium $4,550
Homeowners Premium $2,540
Umbrella Premium $397
Total Package Policy Premium $7,487
AIE Membership Fee $25
Motor Vehicle Law Enforcement Fee $30
Total $7,542
*Insurers are required to charge and collect a,S10.00 Motor Vehicle Law Enforcement Fee annually for every registered vehicle insured on a policy issued or delivered
in the state of New York.
BASIC PACKAGE POLICY COVERAGES & LIMTS
COVERAGES LIMITS OF LIABILITY
AUTOMOBILE
BI Liability-Includes Property Damage $500,000 Each Accident
Medical Payments $5,000 Each Person
Personal Injury Protection SEE NO-FAULT SECTION FOR COVERAGE DETAILS
Supplemental Uninsured/Underinsured Motorist(SUM) $500,000 Each Accident
(*SEE MESSAGE)
*TILE MAM MUM AMOUNT PAYABLE UNDER THE SUM COVERAGE SHALL BE THE POLICY SUM LIMITS,
REDUCED AND THUS OFFSET BY THE MOTOR VEHICLE BODILY INJURY LIABILITY INSURANCE POLICY
OR BOND PAYMENTS RECEIVED FROM,OR ON BEHALF OF,ANY NEGLIGENT PARTY INVOLVED
IN THE ACCIDENT,AS SPECIFIED IN THE SUM ENDORSEMENT
HOMEOWNERS
Coverage A* Dwelling $935,234
Coverage B* Other Structures $93,524
Coverage C* Personal Property $654,664
Coverage D* Loss of Use $187,047
Coverage E Liability $500,000
Coverage F Medical Payments $5,000
*Your combined Coverage A-D limit is$1,870,469.00
PERSONAL UMBRELLA $2,000,000 In Excess of Retained Limit
SH DC 02(01 04) -2-
Please refer to the following coverage sections for detailed information on vehicles,operators,properh,covered and deductibles
ATTACHMENTS
The following Forms,Endorsements and Exceptions to Conditions are part of this policy at the time of issuance.Please read them carefully.
FORM NO. EDITION DATE TITLE
PP 13 01 1299 COVERAGE FOR DAMAGE TO YOUR AUTO EXCLUSION ENDORSEMENT
SH 01 31 08 12 SPECIAL PROVISIONS-NEW YORK
PP 04 09 1200 SUPPLEMENTARY UNINSURED/UNDERINSURED MOTORISTS
ENDORSEMENT-NEW YORK
HO 3000 0106 HOMEOWNERS SPECIAL FORM
HO 04 16 1000 PREMISES ALARM OR FIRE PROTECTION SYSTEM
HO 04 60 1000 SCHEDULED PERSONAL PROPERTY ENDORSEMENT(WITH AGREED VALUE
LOSS SETTLEMENT)
HO 24 93 0502 WORKERS'COMPENSATION CERTAIN RESIDENCE EMPLOYEES -NEW YORK
PP0001 0698 PERSONAL AUTO POLICY
PP 01 79 0409 AMENDMENT OF POLICY PROVISIONS-NEW YORK
PP 03 05 0886 LOSS PAYABLE CLAUSE
PP 03 19 0886 ADDITIONAL INSURED-LESSOR
PP 03 21 0698 LIMITED MEXICO COVERAGE
PP 03 46 0603 RENTAL VEHICLE COVERAGE ENDORSEMENT-NEW YORK
PP 03 64 1200 SINGLE LIABILITY LIMITS-NEW YORK
PP 03 65 0886 FULL COVERAGE WINDOW GLASS-NEW YORK
PP 04 10 1200 SINGLE SUPPLEMENTARY UNINSURED/UNDERINSURED MOTORISTS
LIMITS-NEW YORK
PP 05 87 0111 PERSONAL INJURY PROTECTION COVERAGE-NEW YORK
PP 05 88 0111 ADDITIONAL PERSONAL INJURY PROTECTION COVERAGE-NEW YORK
PP 05 93 1191 OPTIONAL BASIC ECONOMIC LOSS COVERAGE-NEW YORK
SA 00 87 0112 FULL COVERAGE WINDSHIELD REPAIR-NEW YORK
HO 04 90 1000 PERSONAL PROPERTY REPLACEMENT COST LOSS SETTLEMENT
HO 24 86 1002 PERSONAL INJURY-NEW YORK
LC 01 32 03 10 AMENDMENT OF CUSTOMPAC POLICY PROVISIONS-NEW YORK
SA 00 83 1009 ONECHOICE CUSTOMPAC AMENDATORY ENDORSEMENT-NEW YORK
SH 04 20 0104 SPECIFIED ADDITIONAL AMOUNT OF INSURANCE FOR COVERAGE A-
DWELLING FORMS HO 2000 AND HO 3000 AND HO 3000 WITH SH 00 15 ONLY
SH 23 85 0104 WATER BACK UP AND SUMP DISCHARGE OR OVERFLOW-NEW YORK
SR 00 31 0606 ONECHOICE CUSTOMPAC
G13953 0104 ONECHOICE UMBRELLA ENDORSEMENT
G 13954 0104 ONECHOICE UMBRELLA AMENDATORY ENDORSEMENT-NEW YORK
AUTOMOBILE INFORMATION
NO FAULT COVERAGES
COVERAGES LIMIT PREMIUM
Basic Personal Injury Protection(PIP) $50,000 $319
Optional Basic Economic Loss(OBEL) $25,000 $12
Additional Personal Injury Protection(APIP) $100,000 $24
Aggregate No-Fault Benefits Available $175,000 $355
SH DC 02(01 04) -3-
Maximum Monthly Work Loss $4,000
Other Necessary Expenses(Per Day) $50
Death Benefit $2,000
Additional Death Benefit $3,000
YOUR COVERED VEHICLE 1 -2005 JEEP GRAND CHEROKEE LIMITED
VEHICLE TYPE USAGE IDENTIFICATION NO. TERRITORY Vehicle Segmentation
Truck Commuting Short 1J8HR58N35C560969 128 Mid-Size Non-Lux SUV
0-3 miles
PRIMARY GARAGE LOCATION RATED OPERATOR
14 Arlington PI STEVEN VESPIA
Rye Brook,NY 10573-1711
COVERAGES: LIMIT DEDUCTIBLE PREMIUM
Damage to your Auto-Collision A.C.V. $500 $294
Damage to your Auto-Other Than Collision A.C.V. $500 $110
Full Safety Glass Coverage IN OTC
A.CV.Means "Actual Cash Value"
YOUR COVERED VEHICLE 2 -2017 JEEP GRAND CHEROKEE LIMITED
VEHICLE TYPE USAGE IDENTIFICATION NO. TERRITORY Vehicle Segmentation
Truck Commuting Mid 1C4RJFBGIHC603292 128 Mid-Size Non-Lux SUV
4-14 miles
PRIMARY GARAGE LOCATION RATED OPERATOR
14 Arlington PI HOPE VESPIA
Rye Brook,NY 10573-1711
COVERAGES: LIMIT DEDUCTIBLE PREMIUM
Damage to your Auto-Collision A.C.V. $500 S419
Damage to your Auto-Other Than Collision A.C.V. $500 $149
Full Safety Glass Coverage IN OTC
A.C.V.Means"Actual Cash Value"
LOSS PAYEE:
Lienholder Additional Interest
Ally Bank Lease Trust Ally Bank Lease Trust
PO Box 8105 PO Box 8105
Cockeysville,MD 21030-8105 Cockeysville,MD 21030-8105
YOUR COVERED VEHICLE 3-2018 JEEP COMPASS LATITUDE
SH DC 02(01 04) -4-
VEHICLE TYPE USAGE IDENTIFICATION NO. TERRITORY Vehicle Segmentation
Truck Pleasure 3C4NJDBB2JT161527 128 Compact Non-Lux CUV
PRIMARY GARAGE LOCATION RATED OPERATOR
14 Arlington PI N/A
Rye Brook,NY 10573-1711
COVERAGES: LIMIT DEDUCTIBLE PREMIUM
Damage to your Auto-Collision A.C.V. $500 $405
Damage to your Auto-Other Than Collision A.C.V. $500 $133
Full Safety Glass Coverage IN OTC
A.C.V.Means "Actual Cash Value"
LOSS PAYEE:
Lessor/Lienholder
CAL
PO Box 2473
Alpharetta.GA 30023
OPERATORS(0),NON-OPERATORS (N)AND EXCLUDED OPERATORS(E)
LICENSE INFORMATION CREDITS AND DISCOUNTS
OPER DATE OF SEX MARITAL STATE NUMBER FIRST LIC. GOOD DRV ACC.PREV
(O/N/E) BIRTH (M/F) STATUS STU TRN DATE
OPER NO.: 1 of 3 NAME:STEVEN J VESPIA
O xx/xx/1948 M M NY xxxxx7536 N Y 6/12/2016
OPER NO.:2 of 3 NAME:HOPE B VESPIA
O xx/xx/1950 F M NY xxxxx6705 N N
OPER NO.:3 of 3 NAME:ASHLEY VESPIA(OWN
INS
N xx/xx/1985 F S NY N N
DISCOUNTS
DRIVER VEHICLE DISCOUNT AMT.
Accident Prevention Course Discount 1 $137
3 Year Clean Discount 1 $48
5 Year Clean Discount 2 $278
Core Discount-Homeownership/Multi ALL $1,445
Car
Package Discount ALL $1,141
Air Bag Discount ALL $15
Anti-Lock Brakes ALL $191
SH DC 02(01 04) -5-
Security System Discount ALL $46
Electronic Stability Control Discount 2,3 $509
Running Lights 2,3 $73
AUTOMOBILE PREMIUM INFORMATION
COVERAGE VEH#1 VEH#2 VEH#3 VEH#4 VEH#5
PREM PREM PREM PREM PREM
BI Liability-Includes Property Damage $884 $779 $737
Medical Payments $5 $3 $4
Damage to your Auto-Other Than Collision $110 $149 $133
Damage to your Auto-Collision $294 $419 $405
Optional Basic Economic Loss(OBEL) $5 $3 $4
Basic Personal Injury Protection(PIP) $125 $88 $106
Additional Personal Injury Protection(APIP) $10 $6 $8
Supplemental Uninsured/Underinsured $91 $91 $91
Motorist(SUM)
Total Vekide Premium: $1,524 $1,538 $1,488
AUTOMOBILE PREMIUM $4,550
TOTAL AUTOMOBILE PREMIUM $4,550
AUTOMOBILE RATING DATA
RATING TIER RATING DATE RISK STATE
997 5/6/2019 NY
ACCIDENTS AND CONVICTIONS
OP USED IN OP USED IN OP USED IN
NO CODE RATING DATE NO CODE RATING DATE NO CODE RATING DATE
1 AF N 2/23/2016
HOMEOWNERS INFORMATION
INSURED PREMISES AND DEDUCTIBLES
RESIDENCE PREMISES
14 ARLINGTON PL
RYE BROOK,NY 10573-1711
SECTION 1 DEDUCTIBLE
We will pay only that part of the total of all loss and expense payable under Section 1 that exceeds:S 1,000
SH DC 02(01 04) -6-
ADDITIONAL COVERAGES
Extended Dwelling Replacement Cost
Limit:25%
Water Backup
Limit:$5,000
Deductible:$250
!f you have chosen the Scheduled Personal Property Endorsement please refer to that section which appears at the end of these policy declarations.
HOMEOWNERS PREMIUM INFORMATION
BASIC PREMIUM $2,388.00
SCHEDULED PERSONAL PROPERTY $152.00
UMBRELLA $397.00
TOTAL HOMEOWNERS PREMIUM $2,937
POLICY CREDITS
Included in the above premium are the following credits:
Protective Device Discount Account Discount
Prime Time Discount
RATING INFORMATION
RISK STATE RATE TIER OCCUPANCY TERRITORY FAMILIES CONSTRUCTION YEAR BUILT
NY 997 PRIMARY 102 1 FRAME 1985
FEET TO HYDRANT MILES TO STATION PROTECTION CLASS BUILDING CODE GRADING ROOF TYPE
0-500 0-5 4 99 Other
SOLID FUEL STOVE TAX CODE RATING DATE
N 05-06-2019
ONECHOICE UMBRELLA LIABILITY ENDORSEMENT
Limit of Liability: $2 ,
000 000
Self Insured Retention Limit: $1,000
MINIMUM REQUIRED UNDERLYING LIMITS OF LIABILITY
Line of Business Minimum Required Underlying Limit
Automobile Liability including licensed $250,000 Bodily Injury per person
recreational vehicles(and Underinsured Motorist $500,000 per accident and$100,000 Property
Coverage where applicable) Damage or$300,000 Combined Single Limit
Homeowners Liability including unlicensed $300,000
recreational vehicles
Watercraft Liability $250,000 Bodily Injury per person
$500,000 per accident and$100,000 Property
Damage or$300,000
All other types of Liability exposures $300,000
SH DC 02(01 04) -7-
SCHEDULED PERSONAL PROPERTY
DESCRIPTION APPRAISAL FORM NUMBER AMOUNT OF INSURANCE
BILL OF SALE
JEWELRY NOT IN-VAULT
1.1 LADIES 14K WHITE GOLD 3 STONE 18 5I2009 HO 04 60 $12,000
RING DIAMOND ROUNDBRILLIANT-
CENFOS DIAMOND 175 CT 7.86MMX5.12
J COLORSI CLARITY SIDE
DIAMONDS 181 CT TW I COLOR SI2
CLAR16.2 MM.
2.18KT MACRO BICEGO RING 2/2712010 HO 04 60 $2,628
TOTAL JEWELRY NOT IN-VAULT PREMIUM:$152 TOTAL JEWELRY NOT IN-VAULT COVERAGE$14,628
TOTAL SCHEDULED PERSONAL PROPERTY PREMIUM$152
Includes copyrighted material of Insurance Services Office,Inc.with
its permission.Copyright,Insurance Services Office,Inc.1993-2020
IMPORTANT NOTICES
SH DC 02(01 04) -8-
Affidavit of Exemption to Show Specific Proof of Workers' Compensation Insurance
Coverage for a 1, 2, 3 or 4 Family, Owner-occupied Residence
"This form cannot be used to waive the workers'compensation rights or obligations of any party."
Under penalty of perjury, I certify that I am the owner of the 1, 2, 3 or 4 family, owner-occupied residence
(including condominiums) listed on the building permit that I am applying for, and I am not required to show
specific proof of workers' compensation insurance coverage for such residence because (please check the
appropriate box):
❑ I am performing all the work for which the building permit was issued.
❑ I am not hiring,paying or compensating in any way,the individual(s)that is(are)performing all the work
for which the building permit was issued or helping me perform such work.
I have a homeowners insurance policy that is currently in effect and covers the property listed on the
attached building permit AND am hiring or paying individuals a total of less than 40 hours per week
(aggregate hours for all paid individuals on the jobsite) for which the building permit was issued.
I also agree to either:
♦ acquire appropriate workers' compensation coverage and provide appropriate proof of that coverage on
forms approved by the Chair of the NYS Workers' Compensation Board to the government entity issuing
the building permit if I need to hire or pay individuals a total of 40 hours or more per week(aggregate hours
for all paid individuals on the jobsite)for work indicated on the building permit,or if appropriate,file a CE-
200 exemption form; OR
♦ have the general contractor, performing the work on the 1, 2, 3 or 4 family, owner-occupied residence
(including condominiums)listed on the building permit that I am applying for,provide appropriate proof of
workers' compensation coverage or proof of exemption from that coverage on forms approved by the Chair
of the NYS Workers' Compensation Board to the government entity issuing the building permit if the
project takes a total of 40 hours or more per week(aggregate hours for all paid individuals on the jobsite)for
work indicated on th building permit.
(Signatu a of Homeowner) (Date igned)
Home Telephone Number
(Homeowner's Name Printed)
[;-o,,,, 7dayProperty Adddress thatreequires the building permit:
Once notarized,this BP-1 form serves as an exemption for both workers'compensation and disability benefits insurance coverage.
CHRISTINA FUENTES NY-WCB
BP-I (12/08) NOTARY PUBLIC-STATE OF NEW YORK
NO.01 FU6138678
QUALIFIED IN WESTCHESTER
COMMISSION EXPIRES l�1