Loading...
HomeMy WebLinkAboutSP20-001PER SEC TYF JOE 0% co ES' ✓cC TCO # FEE DATE INSPECTION RECORD DATE I NSP FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING RGH PLUMBING GAS CI SPRINKLER ELECTRIC 0 LOWmVOLT m ALARM 0 AS BUILT FINAL 34/-JK6690 eER APPROVALS BR 19 f� J, rG'vl.yV OTC VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914)939-0668 Christopher J. Bradbury wwwtyebrookn .gov TRUSTEES BUILDING&FIRE INSPECTOR Susan R. Epstein Steven E. Fews Stephanie J. Fischer David M. Heiser Salvatore W. Morlino CERTIFICATE OF COMPLIANCE February 20,2025 RSP Group LLC PO BOX 227 Rye,New York 10580 Re: 90 South Ridge Street,Rye Brook,New York 10573 Parcel ID#: 141.27-1-9 Sign Permit#20-001 issued on 1/22/2020 for New Stylized Building Numbers This certifies that the new stylized building numbers;"90",installed under the above captioned permit has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to D IE C I M W E BUILD R ENT For office use only: DPERMIT*5 c�d—� FEB ' 7 2025 VIL OF RYE OK ISSUED: /- )a—CU 38 KING STRE YE BROOK, YORK 10573 DATE: o}•-7—aS VILLAGE OF RYE BROOK 9 FEE:9Q�O-- PAID,* BUILDING DEPARTMENT w l ov 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 +*ss*r+rrw*rrrwtwsrrrrss►ssssssstsrtrrsssrsrrrrtrrrtrtss***s*w**wwwrasrsrsrssrssrrrrssrat*rrts*rt*rt**trr*rt*sssrws+srtswstssrrssr Address: 9D S A,+a&t r Q Occupancy/Use� i,0,",W ,,a L- Parcel ID#: ^Q, c� 7 —�— 7 Zone: oq—S Owner: P500 Grv-p Ii/LL Address: 9U S x/*+ z ci— P.E./R.A.or Contractor: (f Qe_a 7l.',2 - a9P �PJ/9�Address: Person in responsible charge: --701;1 (�/4 at./,O/Q 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 YORK,COUNTY OF WESTCHESTER as: being duly swom,deposes and says that he/she resides at (Print Name of Applicant) (No.and Street) in �XG �f'Yf L` ,in the County of Ll/�d 1d in the State of N y ,that (Cityllbwn/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: �"v �� S y�/�`° �Nfl ,4 5 /7 �e.' 0 � 0 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 Sworn to before me this day of r , 20�� day of , 20 Signa roperty Owner Signature of Applicant �•«�y� �1/6ah�k ame of Property Owner Print Name of Applicant Notary Public Notary Public SHARI MEIJLLO Notary Public,State of New York 6/l i2o2a No.OIME61WO63 Qualified In Westchester County Commission Expires January 29.20z--? E BRC�/s, if 1932 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 : / V so(A4 P , du Sr/ 'U-" / DATE: 2- / y - zoZ� PERMIT# ��C v (�C� ISSUED:-7-7() SECT: /41/ Z7 BLOCK: LOT: I LOCATION: LU -+ J t } Li' I \� OCCUPANCY: .1 ❑ 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 (J l" Z c ✓� ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION cl FINAL ❑ OTHER S Building Permit Check List&Zoning Analysis Address: ` O S ��� S► - sBL �'� . Z� l Zone: Use: Const.Type:__TV_,U- Other. Submittal Date: k 2 Z3 Revisions Submittal Dates: Applicant: S? 0.�� L-L C_ Nature of Work: G N S NN t- C.T`/L (Z r. ✓t t'A i N Reviews:ZBA DEC 2 7 2019 PB: BOT: Other. NEE OK ( ( ) FEES:Filing: BP: C/O: Legalization: ( ) ( ) APP: Date& Notarized: SB : Truss 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:Date Stamped Seale& ✓ Copies: Z Electronic. Other. ( ) (�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. (-) O 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: ► t s Z o approval LS o notes: ( )ZBA mtg.date: approval:- notes: APPROVED ( )PB mtg.date: approval:- notes: REQUIRED EX19IING PROPOSED NOTES Date: Area: Circle: Frorr�tataee: Front: Front: Sides: Rear. Main Cov Accs.Cov FL H Sb: Sd.H Sb: GFA. Tot : Ft.hw: P Height/Stories: notes: y BUILDING DEPARTMENT �R C0 `l LS VILLAGE OF RYE.BROOK938 KING STREET RYE BROOK,NY 10573DEC 2 3 2019 (914)939-0668 FAX(914)939-5801 VILLAGE OF RYE BROOK UILDING DEPARTMEN 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: 90 South Ridge St. Date of Submission: Parcel ID#: t LA1 •Z:� -" I - Zone: OB-S Proposed Improvement(Describe in detail): APPLICANT CHECK LIST: Add address numbers iNI LS I BE COMPLETED BY THE APPLICANT The following items must be submitted to the Building to the front of the building Department by the applicant-no exceptions. 1. ( -Completed Application n 2. ( 4 Two(2)sets of sealed plans. (one full size{maximum Property Owner: KSP C'e's (-1vC- allo%%ahle plan si/c =36"x 42") and one 11"x17•) Address: Q S 14, 3. (, )Two(2)copies of the property survey. 4. ( )Two(2)copies of the proposed site plan. SK2 Phone# /t-/ - OL I/ J 5. (i)One electronic/disc copy of the complete-40 application materials. Applicant appearing before the Board: 6. ( )Filing Fee. Creative Image Design, Inc. 7. ( 'Any supporting documentation. Address: 200 Harvard Ave. Stamford, CT 8. ( )HOA approval letter. (ifapplicable) 9. (.-(Photographs. Phone# 914-937-9456 10.(-1) Samples of finishes/color chart. (a sample board or model may be presented the night of the meeting) Architect/Engineer: 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. Sworn to before me this J-0 Sworn to before me this day , 200 day of 520 ignature of Property Owner Signature of Applicant /Z911%, 04t,&I "fr Print Name of Propert}Owner Print Name of Applicant Notary Public Notary Public uORO .MALONEY •otary Public,State of New York No. 4881977 'nGfied in Rockland County Expires Jon. 12,23 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, January 15, 2020 NAME S LOCATION TYPE OF APPLICATION MOTION SECOND APPROVED REJECTED APPLX 2 Magnolia Dr Egress Window/For Consent 4875 (Rosner) Finished Basement. Agenda 8 Osborne Ave(Dix) Roof Top Solar Array& Consent 4876 System/ Agenda 67 Bowman Ave( Install 6'Privacy Fence In Consent 4877 Trayner) Rear Yard, 4' in Side Yard Agenda 570 Westchester Ave Re-Appearance-New Two 4860 (568 Westchester Family Modular Residential Realty) 158 S. Ridge St New Sign "Massage Envy" 4878 90 S. Ridge Street New Address Sign " 90 " 4879 (RSPG Group LLC) 2 Charles Lane 2nd Story Addition,Rear 4880 (Kaplan) Addition,New Front Porch, &Wood Deck ML NM MR SE JM SF AC AW1 JB CREAT-2 ACORO CERTIFICATE OF LIABILITY INSURANCE DATE / 12/2020/2019Y) 019 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 endorsements. PRODUCER 203-799-2327 CONTACT James Pascarella Orange Insurance Center, Inc. PHONE 203-799-2327 FAX 203-799-1931 325 Boston Post Rd.Suite 2B A/c,No,E 4� (A/C,No PO BOX 946 E-MAIL Orange, CT 06477-0946 A DRESS, James Pascarella —__ INSURER(S)AFFORDING COVERAGE NAIC# NSURERA:The Hartford Insurance NSURED INSURER B reative Image Design Inc. 200 Harvard Ave.Ste I I N RER C Stamford,CT 06902 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 7YPEOFINSURANCE ADDLSUBR pOLICYNUMBER POLICY EFF POLICYEXPITR LIMITS A COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE ❑OCCUR 31SBAPJ0271 03/21/2019 03/21/2020 DAMAFIR zMGE TO RENTED SE $ 1,000,000 X Business Owners MED EXP(Anyoneperson) $ 10,000 PERSONAL&ADV INJURY $ 2,000,600 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 POLICY❑jE8T LOC PRODUCTS-COMP/OPAGG $ 4,000,000 OTHER, $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) ANY AUTO BODILY INJURY Perperson) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILYBODILY INJURY Per accident $ AUT OD ONLY NO 09 ONEY Per PERTY AMAGE $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If Iyes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Village of Rye Brook 938 King .St. AUTHORIZED REPRESENTATIVE Rye Brook,NY 10573 James Pascarella ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ACC) CERTIFICATE OF LIABILITY INSURANCE F .A-(MMIDD/YVYY) 12/20/19 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). CONT PRODUCER NN2237 _NAME: T Sharon Stein FERENCE-GRAY INS BROKERAGE LLC PHONE o.Ext);914-937-9456 FAX No 19 MILL ST E-MAIL ADDRESS: PORT CHESTER,NY 10573-3326 INSURE S AFFORDING COVERAGE NAIC e INSURER A: Eric Insurance Company 26263 INSURED INSURERB:__Erie Insurance Property&Casual Company 26830 Creative Image Design,Inc. INSURIERc: Erie Insurance Exchange 26271 180 E.Prospect Avenue INSURER D: Erie Insurance Company of New York 16233 Mamaroneck,NY 10543 INSURER E: Flagship City Insurance Company 5585 INSURER F: COVERAGES CERTIFICATE NUMBER: N/A REVISION NUMBER:NIA 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 I ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MMIDD,YYY MMIDD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ MA-,E To RENTS CLAIMS-MADE QCCUR PREMISES tEa occurrence S MED EXP(Any one person) S PERSONAL&ADV INJURY S GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY 0ECOT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY Ea BINErnSINGLE LIMIT $ 1,000,000 ANY AUTO BODILY INJURY(Per person) S OWNED SCHEDULED AUTOS ONLY X AUTOS Q09 7130216 9/21/19 9/21/20 BODILY INJURY(Per accident) S HIRED X NON-OWNED PROPERTY DAMAGE S IAUTO ONLY AUTOS ONLY Per accident S UMBRELLA LIAR OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I RETENTIONS $ WORKERS COMPENSATION I PER H- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANV PROPRIETOR/PARTNERfEXECUTIVE E.L.EACH ACCIDENT S OFFICER/MEMBER EXCLUDED? N I A (Mandatory In NH) _E.L DISEASE-EA EMPLOYEE S If yes.describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S i DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Village of Rye Brook THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 938 King Street ACCORDANCE WITH THE POLICY PROVISIONS. Rye Brook,NY 10573 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ACORDs provided by Forms Boss.www.FormsBoss corn: (c)Impressive Publishing 800-208-1977 NYSIF New York State Insurance Fund WESTCHESTER ONE,44 SOUTH BROADWAY, LOTH FLOOR,WHITE PLAINS, NY 10601-4411 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE r CREATIVE IMAGE DESIGN, INC .�{_2y �, 200 HARVARD AVE# 101 ?. -- STAMFORD CT 06902 Al SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER 90 S.RIDGE STREET CREATIVE IMAGE DESIGN, INC VILLAGE OF RYE BROOK 200 HARVARD AVE# 101 938 KING STREET STAMFORD CT 06902 RYE BROOK NY 10573 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE W2372 963-5 659196 10/02/2019 TO 10/02/2020 12/20/2019 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2372 963-5, 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 SHARON STEIN CREATIVE IMAGE DESIGN, INC TWO PERSON CORPORATION 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. BY CAUSING THIS CERTIFICATE TO BE ISSUED TO THE CERTIFICATE HOLDER, THE POLICYHOLDER UNDERTAKES TO PROVIDE THE CERTIFICATE HOLDER 30 CALENDAR DAYS' NOTICE OF ANY CANCELLATION OF THE POLICY. NEW YORK STATE INSURANCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 435697383 1 I.7r Z