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Home My WebLink AboutBP20-079PERIV SECT TYPE �06 t OWN CO N1 EST. �CO # TCO # FEE DATE INSPECTION RECORD DATE FOOTI N G FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING RGH PLUMBING/ 2Z rAS SFR�NKLER � --� � ��_ ELECTRIC _ LOW -VOLT ALARM a AS BUILT FINAL INSP �Q,�rOr�S 9/7- SO �' S 3^75 � -/ �- �-S/pc�no �ly � 7/-1�.� _�.�� /_ �i 5 f ��/ �a>�a"moo ��c��c e ""• � +': /� i �i :. .. :� �• VILLAGE OF ��E BROOK WESTCHEST_ COU , NEW PORK NO: 22-191 Certificate of Occupaucp This is to certify that C I 4�Yc� �Sl e y ynctl� t yin CPS CGS Silvermav7 of, ROE �rc I y 7 having duly filed an application on (��l'r)/�f'I� �, 20 c�oZ requesting a Certificate of Occupancy for the premises known as, /VCQd IC )d D V e , Rye Brook,NY, located in a R",-C15 Zoning District and shown on the most current Tax Map as Section: 1, 5, 3 0 Block: ! Lot: and having fully complied with the requirements of the Building Code and the Zoning Ordinance under Building Permit No. G (P 7 , issued .1/ 20 6,qQ ,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: Construction: for the following purposes: /V euj Window /0 n�z--/7017 S t. 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 height sh nor shall the building be moved from one location to another until a permit to accomplish such change has b n fined from th uilding Inspector. Building Inspector,Village of Rye Brook: Date: DEC 3 2022 D 2 BUILD R EN,I, For office use L.0 PERMIT# 0U0— Q 79 VIL OF RYE K ISSUED: j -9-w DEC - 8 2022 938 KING STRE YE BROOK, YORK 10573 DATE://al- J 9 -06 O� FEE: &CDZ5- PAID= VILLAGE OF RYE BROOK LBUILDING DEPARTMENT 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 Address: Z Occupancy/Use: Parcel ID#: 35-,3,6 - -40 Zone: Owner: V r-779H4 Al' Address: P.E./R.A. or Contractor: YA {Z4_774_1 F/Z� Address: Person in responsible charge: H,410 � ��L- Address:/40 L L' .t� 57-1 *2_670114'v C7 0" 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: /� n 1qA/eE1� 131 L- being duly swom,deposes and says that he/s)Zresides at 17 /-Z5W CFh 73LF �-7k'. (Print Name of Applicant) (No.and Street) in /P ��/�G ,in the County of T 17 � L��J in the State of G% that 1<1 (City/Town!Village) he/ as 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:S- p , 00 o for the construction or alteration of: 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. L Sworn to before me this / Sworn to before me this R3 day of Q 1 , 20 day of &,m 6C P_ 20 'Z Siena ur ofPropertyOmai& Signature of Applicant Print Name Property Owner �� 30 �A ��i� Print Name of Applicant � '••Gomm/e•'•�,Z'i — Notary Pulffic = q0� ' r" — No Public C7 S — rY Q-) C-1 kcc , ,`r. QyE BRC�� 0 1982 BUILDING DEPARTMENT ❑BUILDING INSPECTOR ASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK / y CODE ENFORCEMENT OFFICER 938 KING STREET • RYE BROOK,NY 10573 (914) 939-0668 FAx (914) 939-5801 www ryebrook.org - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS: DATE: ,�) I � l L UL L� PERMIT# O^ ISSUED: ECT: l BLOCK: LOT: LOCATION: ��ti�.9 ' ir1 �C 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 �r ❑ NATURAL GAS ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER �yE BRC�k. cu � 1982 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 vV`%l Y " y DATE: ✓ ',1�� PERMIT# ISSUED:6 i SECT: ' BLOCK: LOT: LOCATION: "� v' -5��` OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... Q 'ACCEPTED ❑ REJECTED/ REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING t'A i 1 — Ce ❑ 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 . O'cQy6[3R(luk� 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 V O DJ?-A-r —k> "I (/ DATE: t 12L` �-ZZ PERMIT# - ISSUED: ^ SECT: BLOCK: LOT: LOCATION: k�jam- -�J `� ��-^� �( 25� OCCUPANCY: r� VIOLATION NOTED THE WORK IS... ❑ ACCEPTED REJECTED/REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING [I INSULATION �— ❑ NATURAL GAS ❑ L.P. GAS _-2 \J ]EL rN (L ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL �`QV C- ❑ OTHER o��yE[3Rov�� cu � '9a2 BUILDING DEPARTMENT UILDING 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 v 0 DATE: 2 1 [,Z-z PERMIT# ISSUED: SECT: BLOCK: LOT: LOCATION: �� [� 1 � L�C�� OCCUPANCY: ' C) ❑ VIOLATION NOTED THE WORK IS... kCCEPTED ❑ REJECTED/RuNSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ NSULATION NATURAL GAS L.P. GAS ❑ FUEL TANK A . ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER : QI \ N y O Ly s W *k N a CA a w H `p a cn M Ln M �r .M-+ Lin a W C (,� �G p, t rA 00 : wA3004 s t o � � t' wr V o < C W z w � U R. t p EC ENPI ��E (lRC>v. YED EGm 2 4 2022 BUIL t� Dom. MENT VIL E OF RYE K VILLAGE OF RYE BROOK 938 Kitt T RYE B NY 10573 AUG 2 4 2022 1 BUILDING DEPARTMENT (914)9 939-5801 1 VILLAGE OF RYE BROOK or BUILDING DEPARTMENT ELECTRICAL PERMIT APPLICATION Westchester County Master Electricians License Required FOR OFFICE USE ONLY BP#: LP 4: Approval Date: AUG 2 inii . A Permit Fee: S Approval Signature: Other: Disapproved: (fees are coo-ntastdabk) 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 re, ove 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. I.Address: 23" [) �jW� SBL: �_ 'Lome:EIZJ_ 2.Property Owner: clx�SI L AMMMI Address: Phone#: l)"�o I-53 Cell#: ,01AI email: 3.Master Electrician:N 1 410 1 Q_5 F� f-I"t Z'ZA Address:8•F of ,, , �1 Whit- l Af 10" Lie.#:�$�3Phone#g14-`�2? �5V ICeIII#: email:0" (PpQ1a.�,�lLfrltZl(p��i�✓tc � Company Name: l F tWa ��QG-1'7'1 L Address: fu-I� * R) Ir OU IQ Ins hN IO Ub 4.Proposed Electrical WorkLFixture Count:A wia, Qoonn- CA F 1 o ilhc 1 "}1 IL Ktv 11'�U'rn V6Lvi I (9)swl iguus +dw- t -( 1-7) r dLvrE I t i6_w I} 6kL S b I t wort rL (71x I 5 4 tt,r,rr*rss+r,r*t**,r,tr*,t****ria*�****t*►,t**tr►**r,r*,►try►rr*e,r*rrserofet*o**,rt,w+eu*tatr,►,►e*rt,r,►,►,r*,t,r,►*rrr,rt�t**,t• STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: IN i C 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 ✓a r for the legal owner and is duly authorized to make and file this application. (indicate architecr_contractor.agent.anomt%.etc) The undersigned further states that all statements contained herein are true to the bat 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 1 b Sworn to ore me s J s+day of v ` 20 1 da off U ,20 afar ope Owner o Ap is Prim Name of Property Owner Print 1��VP7 &! L— ELAINE FISHER HAVER ``- Notary Public Public NOTARY PUBLIC-STATE OF NEW VORK Notary ttAITAR MARKOVIC No. 02MA6219168 wry Public Stats of New York ` Cuollfled In Weitch*SlOf Cctun Fie9.No.400359691 My Commission Expifes �O� Qualified in Westchester oun Commission Exp—Is D 7.P Z Z 3/21119 STATEWIDE • Service With lntegri�v 21 • . Main Street, Suite 203, Fishkill, NY 12524 SWIS JOBAPPLICATION0. Office Use Elect. Permit# �L _ �% Date Bldg Permit# 0(=)o O 7 9 Scl Ft Temp# Utility ID# Final Certificate# City/Village ' Zip Township County i LG i b�-�'73 1. Address �/ 1 l} y� f Cross Street SeJi1_hj� 2) Block / Lot Owner Name/Address(If different than above) J, {; j `�, ,� , Z i,y�- n/ �. � Contact Number f/j - 5t f 175 ❑Basement ❑ 1 st 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 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 ��}r C i ), j� �j VV� �� / I �'Z"��lX.. i 1 .Qi�[ �aLt r� }' !` ( tr o! ►pEY ,vim b � , 0) �� s 141, (� �llil ICI [ r - ( 1 -1) V e �` 1Q� �I � �.t-�� tpie- Krk, /T AUG 2 4 2022 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 forthe above address with anyother 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 ! f 7 / + Date �3 ' 6' nj Addressyl '1 ` /// j City/State -ir !j�`' I / zip Ll LA ` 1c�, rLcense# ID# Phone# _ i yj S -- /7 U State Wide Inspection Services CAD 1080 Main Street Fishkill, NY 12524 awffU A 845 202-7224 Phone 914-219-1062 Fax STATE WIDE INSPECTION SERVICES Email: office@swisny.com Website: www.swisny.com Service With /ntegrlty BY THIS CERTIFICATE OF COMPLIANCE STATE WIDE INSPECTION SERVICES CERTIFIES THAT: Upon the application of: Upon Premises Owned by: Paul Fattizzi Electric Inc. Clifford and Francesca Silverman 8 Fulton Street 23 Woodland Drive White Plains, NY 10606 Rye Brook, NY 10573 Located at: 23 Woodland Drive, Rye Brook, NY 10573 Section: Block: Lot: Electrical Permit Number: EP22-199 135.36 40 Certificate Number: 2022-5262 Building Permit Number: BP20-079 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: 23 Woodland Drive, Rye Brook, NY 10573 The First Floor Kitchen and Powder Room were inspected in accordance with the NYS and NFPA 70- 2017 and the detail of the installation,as set forth below,was found to be in compliance on the 13th day of September 2022. Name Quantitv Rating Circuit Type Powder Room GFCI Receptacle 01 Exhaust Fan 01 Tile Warmer 01 Vanity Light 01 Switches 02 Kitchen Recessed Luminaires 17 Pendant Lights 04 Switches 07 Under Cabinet Lights 02 Dishwasher 01 Refrigerator 01 Microwave 01 Wine Cooler 01 Name Quantity Rating Circuit Type Circuits for Receptacles 02 Circuit For Lighting 01 State Wide Inspection Services did not perform a Rough inspection (Rough Performed by WREIS). A Visual inspection and Final inspection were conducted only. 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. Page 2 = s Ln N N ac p w _ i W T ton, i OpWC, L -1.,-02. * k7 y LTA � � 3 •�rN � "" u cc ~ tf, rr V1 C 'd u� � E■ > S 16 ~ C O �O I tn_ Q o w z ENO X o z A W � r o Aoc A (--) cm, a ac N p z ccc r� m � W -WA � t ON Z u tn E- r z a ON% z o < N Z GT- i i a�E t3RCuh BUIL �DE R�MENT D [E c[E �Y VILy,E OF RYE OK 938 KIN a ET RYE.B ,NY 10573 Ai_ _ 3 1 2021 (914)9 939-5801 VILLAG F RYE BROOK W v _ or J BUILDING DEPARTMENT ELECTRICAL PERMIT APPLICATION Westchester County Master Electricians License Required FOR OFFICE USE ONLY 13 O— O 7 LP#: C>_)/Q/S Approval Date: SEP - 1 Permit Fee: S ZSV !"b Approval Signature: Other: Disapproved: (fees are non-refundable) Application dated, 3/ .3 I is hereby made to the Building Inspector of the Village of Rye Brook NY, for the issuance of a Permit to install an or r ove 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: 23 "t GAA(j��1✓C SBL:122 0 1p Zone: 2.Property Owner: Cl is 5 1 JZW_MAA Address: Phone#:T9115 �-�j�j�j OR- 1 #: Sq,�E email: 1t I l' �2 3.Master Electrician: 1 010 1 Q..S O 11 Z_i1 Address: I F u-t tm St Wh1t& ig" Lic. 3 Phone#(1 ICI'q Z?•d)R Cell#: email:p" ® PMAJ�/�Q�t yU QLC�✓I L•10M CompanyName:`�aAki �QtlILZJ E1e6-6't ( Address: ? -rill fyO 6-1- Rh1-2. f imns N9 1614i 4.Proposed Electrical Work/Fixture Count: 0 M/jW �V ohn— C F I 0 04 TL r fib_ wa*-'ywx 6w-m V v►I Itit (9)6,wI+chis V -i"C v� -C 1�) r0 ddt I �w1 ttkts bt I t 6 WIVI CIA- 4 STATE OF NEW YORK,COUNTY OF WESTCIIESTER ) as: It, 0 L 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 r tAy-a&+-0 l- for the legal owner and is duly authorized to make and file this application. (indicate archittet.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 1 Sworn to be ore me is 3/5 + day of v S, 20 1 da of Hal U 20 atur o ope Owner 1' 6 of Ap ppficke Print Name of Property Owner Print Print s f AplpI i / '-� 9a� �JA 62 FISHER HABER V Notary Public ELAINE Not Public NOTARY PUBLIC-STATE OF NEW YORK MITAR MARKOVIC No. 02HA6219168 Notary public,State of New York Quolftled In Westchoster Count Reg.No.400359691 My Commisslon Explres J �O� a« Qualified in Westchester Coun tV Commission Expires D Z Z 3/21/19 Westcliester Rockland Electrical Inspection Services, Inc. t -Phone: 914-347-3595 DO'NOT WRITE HERE-FOR OFFICE USE ONLY 43 North Lawn Avenuei y Fax: 914-347-3596 Elmsford, NY 10523 - BUILDING PERMIT NO. TEMP# DATE CITY OR VILLAGE ZJP CODE TOWNSHIP STREET AND NO.OR ROAD POLE NUMBER BETWEEN WHAT TWO CROSS STREETS IS PREMISES LOCATED? SECTION BLOCK LOT OCCUPANT'S NAME BUILDING OCCUPANCY OWNER'S NAME AND ADDRESS HOME TELEPHONE NUMBER 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 EACH INSPECTION OUTSIDE BASEMENT 1"FL. 2-FL. 3'm FL. B ILDING IDEPARtMENLU 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❑ ADDITIONAL CI EXPOSED❑ CONCEALED❑ MUST ENTER APPLICANTS IDENTIFICATION NUMBER SERVICE ENTERS BUILDING OVERHEAD C1 UNDERGROUND❑ AVOID DELAYS BY GIVING FULL AND ACCURATE INFORMATION.ALL SPACE MUST BE FILLED IN OR APPLICATION MAY BE RETURNED. NAME OF COMPANY DATE OF APPLICATION SIGNATURE OF APPLICANT X STREET ADDRESS TELEPHONE NO. CITY OR POST OFFICE ZIP CODE LICENSE NO.WHEN APPLICABLE . a a (V N N Q O tf qv `N LZ = Z W c oo �. o � Q a: a Z w z a, w it 3 x ol O WIc Z Z Z O cz 0. U A � o ,•.., O a � � � � v z # ' G OF cn m r a z E- 00 r ^ J Z Z 96 _ A = C Q6 tro I f' a a r r r r y DRC��k BUIL MENT AUG 2 6 2021 � �J VIL E OF RYE K L_ _ 938 KIN EET RYE B ,NY 10573 VILLAGE OF RYE BROOK (914)9 939-5801 EU!LDING DEPARTMENT org PLUMBING PERMIT 7 APPLICATION FOR OFFICE USE ONLY BP#: 00 — O ! 7 PP#: Approval Date: AUG 2 6 IP21 Permit Fee: $ Approval Signature: Other: Disapproved (fees are non-refundable) Application dated }1 3,6011 is hereby made to the Building Inspector of the Village of Rye Brook NY, for the issuance of a Permit to install an 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: 3 (yDocl lC�-+N �� SBL:/35.3o- - 1 O Zone:2—J5 Proposed Work: cc c -, eii w 'u �cr I� /� Q n / L,a h) ;rl K— /•GOM. �i - - I ! k N7r f` Mtn CC rJ 11 r 3.Property Owner: TWI(QVC '-,I�V (my—) Address: C��Q �CA� 1'(� Phone#: /� Cell#: 5�b 'a 5 7-a 118 5 email: Pe a n a C 4 M 4.Master Plumber: 1� d"'t� r'"1 pa . Address:(� 1�cla v-�� S±.8,J 14,lb �f , �� VS v Lic.#:S•q8 Phone#: c/lY-C�-S313 Cell#: email:CAS'}''`n a-3 for Name: 4 r r} P 1 S �o�(.g-G.2j aJ (L@cJi'�""Address: ISM 11d a►nj Q)Yee} �c� 1-1 d 1s,►jy /0 0 - � ,n2 ,5` j 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 1 st Floor r I 2nd Floor 3 Floor 4 Floor 511 Floor Exterior 5.*List Other Equipment/Provide Details: (Notarized Signatures Required Next 2 Pages) t i'21 19 STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: �cly)U C CU �j ( (Yl Geeing 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 for the legal owner and is duly authorized to make and file this application. (indicate architect,contractor,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. Sworn to fore me this I�� Sworn to before me this 19 1 1 day of U`.sl!" 20_Qj_ day of 20=)J_ \\S_ A A. ; Si at e operty Owner Signature of Applicant � OFF. • � 'o I Y�GU`c.i Print Name of Property Owner 7s,� Print Name of Applicant ELAINE FISHER HABER NOTARY PUBLIC-STATE OF NEW YORK�_ �,-� 00 Q)123 Notary Public No. 02HA6219168 Notary Public Qualified In Westchester unnty My Commission Expires 3PIOPQ This application must be properly completed in its entirety and must inchlde 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 andJor not properly signed shall be deemed null and void and will be returned to the applicant. STATE 'OF N___EW YORK�, 3 NOTAR_y pLT Ul n; Qualified in p ,Westchester Courly,' N t.01SF'5040025.' O? Off\.: °'••f/0/VEXP_hm \, , -2 3/21/19 BUILD1 I 9PARTMENT VILLAGE OF RY� OK AUK 2 6 Z�Z� i 938 KING S. ET RYE BR=(}�k,NY 10573 (914)939 (9 44)939-5801 VILLAGE Oi- RYE BROOK BUILDING DEPARTMENT w�rtV.T�'r ak:t�r _____ AFFIDAVIT OF COMPLIANCE VILLAGE CODE §216 ESTORM SEWERS AND SANITARY SEWERS THIS AFFIDAVIT MUST BEAR THE NOTARIZED SIGNATURE OF THE LEGAL PROPERTY OWNER AND BE SUBMITTED ALONG WITH ANY BUILDING OR PLUMBING PERMIT APPLICATION. ANY BUILDING OR PLUMBING PERMIT APPLICATION SUBMITTED WITHOUT THIS COMPLETED AND NOTARIZED FORM WILL BE RETURNED TO THE APPLICANT. STATE OF NEW YOM COUNTY OF WESTCHESTER ) as: 3, r0ko(gy(k G)' Y ((Wkn , residing at, 2 ? VJDC(A-- kxy-y 0-C . (i'riut name) (Atldres;tirhere you lip 0 being duly sworn, deposes and states that (s)he is the applicant above named, and further states that (s)he is the legal owner of the property to which this Affidavit of Compliance pertains at; 2, 3 W®yc `G`^'� pC' , Rye Brook, NY. Further that all statements contained herein are true, and that to the best of his/her knowledge and belief, that there are no known illegal cross-connections concerning either the storm sewer or sanitary sewer, and further that there are no roof drains, sump pumps, or other prohibited stormwater or groundwater connections or sources of inflow or infiltration of any kind into the sanitary sewer from the subject property in accordance with all State, County and Village Codes. (S' net c of Pr(CeIr t>ltfllner(s)) U (Print Name of Property()nncr(s)t Sworn to before me this 1�9m day of t" , 20 0A ELAINE FISHER HABER NOTARY PUBLIC-STATE OF NEW VORK W ^ ClU No. 02HA6219168 (LoIwN Public) Qualified in Westchester County My'Commisslon Expires -3- 3/21/19 Mike Izzo From: Mike Izzo Sent: Tuesday, December 21, 2021 10:32 AM To: Marek Bil Cc: Tara Gerardi; Steven Fews; Laura Petersen Subject: RE: Permit extension BP 20-079 23 Woodland Drive Dear Marik, Your request for a six (6) month extension has been granted, and the new permit expiration date is June 9, 2022. Unfortunately this is the last extension the code allows. Thank you. Aff/c�ae/(T /zza Building& Fire Inspector Village of Rye Brook, NY (914) 939-0668 From: Marek Bil <marek@owconstruction.com> Sent:Tuesday, December 21, 20218:56 AM To: Mike Izzo<Mlzzo@ryebrook.org> Cc:Tara Gerardi <tgerardi@ryebrook.org> Subject: Permit extension Good morning Mr Mike, I hope all is well, I would like to file for extension for six months for the project located at 23 Woodland Drive. Building Permit number: BP- 20-079. Is a longer extension possible ? Powder Room is completed. Client requested to move starting date of the Kitchen renovation project due to appliance delivery delay. At this moment,we are having estimated date of arrival of some appliances in late April and May. But that could also change again. We are planning to start project based on appliance delivery, sometime in 2022, as a clients family cannot be without functioning kitchen for too long. We would appreciate positive consideration of this request. Thank you 1 • Marek Old World Construction, LLC 140 Peaceable Street Redding, CT 06896 203.544 . 9263 2 Mike Izzo From: Mike Izzo Sent: Thursday, June 3, 2021 1:15 PM To: Ashley Cc: 'Marek Bil'; Steven Fews; 'Tara Gerardi'; Laura Petersen Subject: RE:23 Woodland Drive BP-20-079 Extension Request Dear Ashley, Thank you for the email. I am pleased to inform you that a six (6) month extension to your open permit #BP 20-079 has been approved, and that the new permit expiration date is December 9, 2021. 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. lffl and(T Izzo Building& Fire Inspector Village of Rye Brook, NY (914) 939-0668 From:Ashley<ashley@owconstruction.com> Sent:Thursday,June 3, 2021 11:25 AM To: Mike Izzo<Mlzzo@ryebrook.org> Cc: 'Marek Bil'<marek@owconstruction.com> Subject: BP-20-079 Extension Request Hi Mike, I hope all is well.We pulled a permit last year 6/9/20 and it expires on 6/9/21. We would like to file for an extension, as the homeowners plans changed with Covid.We are planning to start the Powder Room renovation this summer,and the Kitchen in the fall. I have attached the permit documents for you reference. Please let me know if you need any more information from me. Thanks! Ashley Old World Constuction, LLC 140 Peaceable Street Redding, CT 06896 1 Building Permit Check List&Zoning Analysis Address: Z 3 VJ0 M--> SBL. ,3 b — l - 4 Zone ZS Use: Z t o Const.Type: Other. Submittal Date: 3 t{ 2 c> Revisions Submittal Dates: Applicant S t t_tr 4Lq,,,44 A tJ Nature of Work: Nt F_L---� U1 LQ C Ate)N o kS t.�, 2 Reviews:ZBA PB: BOT: er. OK ( ( ) FEES:Filing: .S�r, BP: 1 ,Z 1.S- � C/a. Legalization: ( ) (� APP: Dated:_ .-' Notarized ✓ SBL: — truss I.D. Cross Connection: ✓-1 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:Daty�Stamped: ✓ Seal epl '� Copies C Electronic / Ocher. (vy ( ) License: �V/ 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. (LY ( ) 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. (40kB erg,date: 3 l 'L� approval• Z'J notes: ( )ZBA mtg.date: approval• notes: ( )PB mtg.date: approval:- notes: REQUIRED EXISTING PROPOSED NOTES APPROVED Area: Dates ,tUN ' 4 2020 Circle: FrontaQa Front: Front Sides: Rear. Main Cov Accs.Cor. Ft H Sb: Sd.H Sb: GFA: Tot.imp: Ft Im : Paz ' Height/Stories: notes• ( Or.► BUILDING-I}EPARTMENT D `� v `� `E VILLAGE OF RYE'fBROOK MAR - 4 2020 938 KING STREET RYE BROOK,NY 1057 (914)9394668 FAx(914)939-5801 VILLAGE OF RYE BROOK wNkw:Jrye Eook.or 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 yoofthis check list will be removed from t e ARB agenda. Job Address: 2J Date of Submission: ,o Parcel ID#: i _Zone: Proposed Improvement(Describe in detaq): APPLICANT CHECK LIST: L bo. N1 UST BE COMPLETED BY THE APPLICANT The following items must be submitted to the Building ((f 7 Department by the applicant-no exceptions. ✓� I. (•t//Completed Application 2. ( )Two(2)sets of sealed plans. (one full size{maximum Property Owner: CL1 fF Sit- t: ' jkUn allowable plan size=36")C 42"1 and one 1 l"x 17") Address: 1�l� j'ArC'� dyt' j(pf �/ /�/� f J��Zu 3. ( )Two(2)copies of the property survey. r., _ T— '-�- 4. ( )Two(2)copies of the proposed site plan. Phone# ,� .,` �� 5. ( )One electronic/disc copy of the complete Applicant appearing before the Board: application materials. J 6. ( ) Filing Fee. 7. ( ) Any supporting documentation. Address: 8. ( )HOA approval letter. (!f applicable) 1 t iTI 0 '��l0 9. (v'Photographs. Phone# �� . �2 10.( )Samples of finishes/color chart. (a sample board or A /) model may be presented the night of the meeting) � Architect/Engineer:-F A 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 a application not meeting the requirements contained herein. rny Sworn to before +methis Sworn to before me this _ day of �I l�"►' 1 , 20 2-76 day of 120 Signature of Property Owner Co Ci r Y Signatu C of 1�Pllb r cant .. k Print Name o ro y Own Print Namc of Appiisant No ry P tc Notary Public DILYS A.CORREIA 111 Nobq Public, ';t:;te,nf;Jew York No.Olt C` ;82774 C wIffied in;,' v York County C vision- November 5,2022 3/21/19 BUILDING DEPARTMENT D E C E � `-' VILLAGE OF RYE BROOK 938 KING STREET RYE BROOK,NY 10573 MAR - 4 2020 (914)939-0668 FAx(914)939-5801 www.ryebrook.org VILLAGE OF RYE BROOK 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 t e ARB agenda. Job Address: 223 WDUDIMD� �RIVt Date of Submission: Parcel ID#: !?j� " 7� Zone: 2/ APPLICANT CHECK LIST: Proposed Improvement(Describe in detail): M UST BE COMPLETED BY THE APPLICANT t/7P6-Al The following items must be submitted to the Building MOVE aL-1116 //I�Ud�J 1D /l��/.0 Cd_A UV) . Department by the applicant-no exceptions. r - 'cX1, % Ey(.AC� 'J /�• 1. (t/(Completed Application 2. ( )Two(2)sets of sealed plans. (one full size{maximum Property Owner: Coa allowable plan size=36"x 42") and one I I"x17") 3 Address: i�25 TA AT AK 1UP ll/q N y �f�� . ( )Two(2)copies of the property survey. 4. ( )Two(2)copies of the proposed site plan. Phone#1 q 11) 1151 .- 5. ( )One electronic/disc copy of the complete Applicant appearing before the Board: application materials. / 6. ( )Filing Fee. A5f LILY /�(l�//��L11(j 7. ( )Any supporting documentation. 8. ( )HOA approval letter. applicable) Address: LE C � (if9. ()'Photographs. Phone# "tZ 10.( ) Samples of fmishes/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 Sworn to before me this l day of 120 G r`ANC 2020 ..••• �e � �gsion F''•9 i 'Signature of Property Owner I;'UO�ARy �N: Z Signature of Applicant v: pUe� .. Print Name of Property Owner •4••1p.31_2�.ti• J �� Print Name of Applicant Notary Public Ncrary Public III 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, April 1, 2020 NAME & TYPE OF APPLICATION MOTION SECOND APPROVED REJECTED APPL.# LOCATION 15 Beacon Lane Roof Top Solar Array& Consent 4895 (Zubov) System Agenda 4 Wilton Road Roof Top Solar Array& Consent 4896 (Boruch) System Agenda 15 Carlton Rd Roof Top Solar Array& Consent 4897 (Amestoy) System Agenda 2 Hillandale Road Roof Top Solar Array& Consent 4898 (Oling) System Agenda 18 Red Roof Dr Roof Top Solar Array& Consent 4899 (Lungariello) System Agenda 23 Woodland Dr. Moving Window Over,at Consent 4900 (Silverman) Rear Nook Elevation Agenda 1 Churchill Road(St Legalize Front Patio,Cedar J 4901 Lawrence) Privacy Fence, Stair Railing 47 Rock Ridge Dr (2)Rear 2nd Story 4902 (Nurik) Additions,New Deck,Front Addition&Portico 5 Brookside Way New Detached Accessory 4903 (Con Edison) Bldg,New 125K Natural Gas Generator,New Site Lighting&Security Equipment 20 Country Ridge Dr Demo Existing Deck,Build 4904 (Reiss) New Larger Deck. 20 Country Ridge New Front Porch,New 4905 Circle(Hannon) Gable Roof 177 North Ridge Two Story Addition 4906 Street(Lovallo) ML ✓ NM MR SE JM V SF AC MI JB ,. _� - � � "r' _- �`- - -..�. --- .'�4W". w� � i � tip. �� -f��,e .F .• f J�� . � . -'*: ;.� ,g 4�?f `, 7 -_ �*' � '' ^r�� :•h �� P. 6��`� �j. p�rt j '#. $ t_ _ i �.' d� � ,. +a�f ..� _, � o -�__ ,_.. __- __ _ _ - = Rs�' ,._a __ r._3_�. r�i ....,�.:. x y .�: '� � h •— rf'°t - � S - _ ,l'` � �. �� . _ . . - -•- � r �: • ' fir, t �� I _ -ss d Ae is- ii NAM rm , " _ ' _ �� A�tr�' 't1♦ "� i••• ik i• f • d � S t' e, t # :1e w a ' '� rl %nE Ja _ '.i� A i/'iSk � >� -. k � Fr - i �' i -_ /n A r �� i I► \' /s A/sb�- f �' v ♦• k i t ♦♦` t �'' 't �� t � t1. t v ♦��d!1, � t �11�rQIJ � �� •.� a \ ; 11111o/11 C�e:: .��r Ijl/11l1; � ��! 1+1/11+f lk ��1 �1�`i f;.1j1/1111 ��,�y, 1l/lljl_:i;i��r- ,1i�!!/'/11'1 h .1�111�111�1:.'••a ni� ""�¢PI' <(o_ )>��r�4-.''ai=111111:�. _.�. �_1111111 n::es`��z--•.ti1111-�:,_ 1111� s.-�41111 !�(o�y� a : .. N 03 :;•. �;;; j R O N 4,• CC) i: L I�sq � � /rr � �.�•1v: ' Co)> / CC NH � / 3 ` . - Ll F' fLLI — ,. +C.� •�.� U co t° gin . 4� c� o t) a, o<eration A W 0 C/ yry odZi r v#r �y z Q O U p !` LU d o 'C;3 �G0 y`G cr cj <co)> � z Q ,may CAI y i !.'•� Cut 1 •ice t O Vr � ('Y) 1 ��• i r c� •v,o - --_ - --- — - -- - - ----- -- ,ems'�` f.si. . . . . .. . . . . . . . ,+11�/�4 . .=``M1M1111'+!!y _s. . 11.! +l4- ...11.; . . . . . "M1 1j •;:.Yh(.•n__ <Nn�)>� III/N!1 1l1111l1 §aa ^1�11�j1� elol%1��t1• � 'i�:�� o�•� � �d .y ,..: -- 0 ;�/.-. �: 0 ,�M .f''.,cow' '� _ vc�`."" •�` .,ice..:: --' :lvl* :lva ... -dy.E .`�'e7y� �"� • ." r Ac o' CERTIFICATE OF LIABILITY INSURANCE FDATE(MMIDDIYYYY) `� 03/03/2020 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 CONTACT NAME: THE HANNAN AGENCY INC. PHONE . 203-743-6331 FA% Nok 203-798-2849 E�AAIL ADORES - hannanagency®yahoo.com 23 KEELER ST. INSURE S AFFORDING COVERAGE NAIC 0 DANBURY — CT 06810 INSURERA: ATLANTIC CASUALTY INSURED WSURER1: THE HARTFORD OLD WORLD CONSTRUCTION LLC INSURER c: INSURER D: 140 PEACEABLE ST. INSURER E: _ REDDING CT 06896 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE;Li#rED 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 ADDL SUBR — LTR TYPE OF INSURANCE POLICY NUMBER M1/DDY� MWD rD/YYAYPY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE f 1,000,000 CLAIMS-MADE I J OCCUR PREMISES Ea o0curnff"I S 50.000 MED EXP(Anti one person) S 5.000 A L261003275-0 06/18/2019 06/18/2020 PERSONAL a ADV INJURY f 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE f 2,000,000 X JPERO- LOC PRODUCTS-COMPIOP AGG f 2.000,000 POLICY❑ OTHER: f AUTOMOBILE LIABILITY IN I L LIM f ANY AUTO Ea abuderlt OWNED SCHEDULED BODILY INJURY(Per person) f AUTOS ONLY AUTOS BODILY INJURY(Per accident) f HIRED NON-0NMED i PeOPERdTY DAMAGE f AUTOS ONLY AUTOS ONLY I f UMBRELLA UAa OCCUR EACH OCCURRENCE S-- EXCESS LIAB HCLAIMS-MADE AGGREGATE f DED RETENTIONS WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY YIN X I STATUTE ERA ANYPRB OFFICE /MEMB REXC UDEO?ECUTIVE 09/11/2019 09/11/2020 E.L.EACH ACODENT f 100,000 OFFICER/MEMBEREXCLUDED9 Y NIA 3700600119 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE f 100.000 If es,descnbe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 500,000 I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may he attached N more space Is required) CONSTRUCTION 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 BROOK ACCORDANCE WITH THE POLICY PROVISIONS. 938 KING ST, Au ED RESENTATNE RYE BROOK NY 10573 1A9/88-2016 ACORD CORPORATION. rights reserved. ACORD 26(2016/03) The ACORD name and logo are registered rf(arks of ACORD Certificate of Attestation of Exemption Oki from New York State Workers' Compensation and/or Disability and Paid Family Leave Benefits Insurance Coverage "Thu form cannot be used to waive the workers'compensation rights or obligations of any party." The applicant may use this Certificate of Attestation of Exemption ONLY to show a government entity that New York State specific workers'compensation and/or disability and paid family leave benefits insurance is not required. The applicant may NOT use this form to show another business or that business's insurance carrier that such insurance is not required. Please provide this form to the government entity from which you are requesting a permit,license or contract. This Certificate will not be accepted by government officials one year after the date printed on the form. In the Application of Business Applying For: (Legal Entity Name and Address): Home Improvement OldWorld Construction LLC 140 Peaceable St From:23 Woodland Drive Rye Brook NY 10573 140 Redding,CT 06896-3100 PHONE:203-544-9263 FEIN:XXXXX5984 Workers'Compensation Exemption Statement: The above named business is certifying that it is NOT REQUIRED TO OBTAIN NEW YORK STATE SPECIFIC WORKERS'COMPENSATION INSURANCE COVERAGE for the following reason: The business is a LLC,LLP,PLLP or a RLLP;OR is a partnership under the laws of New York State and is not a corporation. Other than the partners or members,there are no employees,day labor,leased employees,borrowed employees,part-time employees,unpaid volunteers(including family members)or subcontractors. Partners/Members: Marek Bil Disability and Paid Family Leave Benefits Exemption Statement: The above named business is certifying that it is NOT REQUIRED TO OBTAIN NEW YORK STATE STATUTORY DISABILITY AND PAID FAMILY LEAVE BENEFITS INSURANCE COVERAGE for the following reason: The business MUST be either: 1) owned by one individual; OR 2) is a partnership(including LLC,LLP,PLLP,RLLP,or LP)under the laws of New York State and is not a corporation; OR 3) is a one or two person owned corporation,with those individuals owning all of the stock and holding all offices of the corporation(in a two person owned corporation each individual must be an officer and own at least one share of stock); OR 4) is a business with no NYS location. In addition,the business does not require disability and paid family leave benefits coverage at this time since it has not employed one or more individuals on at least 30 days in any calendar year in New York State. (Independent contractors are not considered to be employees under the Disability and Paid Family Leave Benefits Law.) I,Marek Bil,am the Member with the above-named legal entity. I affirm that due to my position with the above-named business I have the knowledge, information and authority to make this Certificate of Attestation of Exemption. I hereby affirm that the statements made herein are true,that I have not made any materially false statements and I make this Certificate of Attestation of Exemption under the penalties of perjury. I further affirm that I understand that any false statement,representation or concealment will subject me to felony criminal prosecution,including jail and civil liability in accordance with the Workers'Compensation Law and all other New York State laws. By submitting this Certificate of Attestation of Exemption to the government entity listed above I also hereby affirm that if circumstances change so that workers'compensation insurance and/or disability and paid family leave benefits coverage is required,the above-named legal entity will immediately acquire appropriate New York State specific workers' compensation insurance and/or disability and paid family leave benefits coverage and also immediately furnish proof of that coverage on forms approved by the Chair of the Workers'Compensation Board to the government entity listed above. SIGN HERE Signature: Date_ Exemption Certificate-sNumber 'fi' r* ,Received C 2020-029-754 June 5, ;2020 b 11 NYS Workei+s' Compensation Board CE-200 01/2018