HomeMy WebLinkAboutBP20-111PERMIT # QQ" j I DATE. *7/9100 IXP: 07 _
SECTION Z, )9, %�_ BLOCK I LOT 139
TYPE OF WORK
JOB LOCATIO
OWNER
CON
T.
O#
TCO #
TRACTOR��o/)a0 A`J/)Ci LZC. ( hi l
FEE DATE
INSPECTION RECORD
DATE INSP
FOOTING
FOUNDATION
FRAMING
RGH FRAMING
INSULATION
PLUMBING CI
RGH PLUMBING
GAS 0
SPRINKLER
ELECTRIC 0
LOW4OLT O
ALARM CJ
AS BUILT CI
FINAL
J
7
OTHER APPROVALS
ARB
BOT
PB
ZBA
OTHER
Expired Letter Sent �_' ` J
10/6/2022 Te g n a3
QyE DR
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. 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
August 21,2023
Askar Djabbarkhodjaev&Karina Babakulova
121 Brush Hollow Crescent
Rye Brook,New York 10573
Re: 121 Brush Hollow Crescent, Rye Brook,New York 10573
Parcel ID#: 129.76-1-139
Building Permit#20-111 issued on 7/8/2020 for Replacement Windows
This certifies that the new windows,installed under the above captioned permit have been satisfactorily
completed.
Sincerely,
Steven E. Fews
Building&Fire Inspector
/to
D E(� (� BUILDINdLLYTMENT For office use onl :
V� E � V�/J(�I� PERMIT# '11/
VILLAGE OF RYE BROOK ISSUED: _7—Pj ,a0D O
AUG 1 1 2023 8 KING STREET,RYE BROOK,NEW YORK 10573 DATE: S--1 1 — �0
(914)939-0668 FEE: PAID
VILLAGE OF RYE BROOK ��'R�r`1�, �e0 .°r>?
BUILDI G DEPART T ERTIFICATE 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
r►►•rrwwwwrw►►►►►►►►►►►►►►►r•wwwrw►wwrr►►►►►►►e►►►rs►se►►►►wrw►►►►►►►►►►►►►►►►►•r►►►rrww►►r►►►►►►►►►r►►►rrrrrwrw►wr►►►►►►►►►►
Address: l,L1 &KUStP f 4 ot''0 W C2�S , l-ylG 290IC / IyL( 10. 73
Occupancy/Use: I'rO.M Parcel ID#: o'? (O —J— 13 A Zone: LL
Owner: &KAk Q J Ab/i49 K`}'(,-(J j,4 ✓ Address:
P.E./R.A. or Contractor: Address:
Person in responsible charge: 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:
A5KAP, being duly sworn,deposes and says that he/she resides at L21 Fled SH lA O L(—OLO C,e—F—S
(Print Name of Applicant) (No.and Street)
in &� &WOP— ,in the County of (//EST 6d4 C- S"T EI—) in the State of �J L,that
(City/Town/Village)
he/she has supervised the work at the location indicated above,and that the actual total cost of the work,including all site improvements,
labor,materials,scaffolding,fixed equipment,professional fees,and including the monetary value of any materials and labor which may
have been donated gratis was:$ `f ,
for the construction or alteration of: w I Ai r) P
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 A uq u sT Sworn to before me this
day of 7 ,20 23 day of , 20
Signature of Prop er Signature of Applicant
AS002, D)Ab&AR k-i0t71AE✓
7c:erty O\caner Print Name of Applicant
Notary Public Notary Public
SHARI MEULLO
Notary Public,State of New York
No.O1ME6160063 8/12/2021
Qualified In Westchester County
Commission Expires January 29,20_
cu �
BUILDING DEPARTMENT
UILDING INSPECTOR
eAssiSTANT 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 - - - - - - - - - - - - - - - - - - - -
v5 l\. b FAO ( ? � N Zc
ADDRESS: LATE.
PERMIT# V ISSUED: `V $ECT: BLOCK: LOT:
LOCATION: 1 �x.J\ OCCUPANCY:
❑ Violation Noted THE WORK IS... [;rl PASSED ❑ FAILED REINSPECTION
❑ SITE INSPECTION I —���� REQUIRED
❑ FOOTING
❑ FOOTING DRAINAGE
❑ FOUNDATION
❑ UNDERGROUND PLUMBING NOTES ON INSPECTION:
❑ ROUGH PLUMBING
❑ ROUGH FRAMING
❑ INSULATION 'N'
❑ Natural Gas
❑ L.P. Gas
❑ FUEL TANK
❑ FIRE SPRINKLER
❑ FINAL PLUMBING
❑ CROSS CONNECTION
'149INAL
❑ OTHER
DR
Otty�'�oo aJ✓
Q1, uo vvYr
406 (budvvoaW
VILLAGE OF RYE BROOK
MAYOR 938 King Street, Rye Brook, N.Y. 10573 ADMINISTRATOR
Jason A.Klein (914) 939-0668 Christopher J.Bradbury
-,i-Nti-Nr.r}-ehrook.org
TRUSTEES BUILDING&FIRE INSPECTOR
Susan R. Epstein Michael J. Izzo
Stephanie J. Fischer
David M.Heiser
Salvatore W.Morlino
October 6,2022
Dear Rye Brook Building Permittee,
It has come to the attention of the Building Department that your Building Permit has not been closed out in
accordance with Village Code and is now expired.All Building Permits have a twelve(12) month lifespan
starting from the date of issuance,and the permit expiration date is noted on the front of the permit.
Please note that there is a non-waivable Expired Permit Fee of$500.00 now due in connection with your
expired permit. Once payment is received,your permit will be reinstated for a period of six(6) months.
Please be advised that it is a violation of Village Code to fail to close out a permit,and that a court summons
could be issued,and fines may be imposed on the permit holder and/or property owner for failure to apply
for and obtain a Certificate of Occupancy(C/O) or Certificate of Compliance(C/C),in accordance with
Village Code section 250-10A.
Please note that Temporary C/Os&C/Cs are available in accordance with Village Code section 250-10B
should you require more time to perform whatever work remains in order to complete your project.
Thank you for your attention in this matter,and please feel free to contact this office should you require any
further information.
Michael J. Izzo
Building&Fire Inspector
mizzo lyebroo.orb
/to
cc: Steven E. Fews,Assistant Building Inspector
Tara A. Orlando,Planning&Zoning Secretary
Laura Petersen,Office Assistant
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WINDOW KING
'W.C.Lic.#: 15985-H04 enur I L
( t075 Morris park, ,Bron>,New York 10461
'N.Y.C.-ocA Lic.#; 1171450`Yonkers Lic.#:3979 (718) 7'92-5989
C. SPec1eflzin f 71" T.Lic.#:0603035 g n: ( 8) 239-0800
"Rockland Llc.#H-09683 WindOW5+ Bays - BOWS TOIL-Free: (800) 413-9925
New Jersey Lic.#13VH00055900 SecurityDoors• Fax: (718) 792-6052
# Putnam Lic.#Pc5978 Patio Doors - Entry DOOPS www.windowlcing.biz
Nassau Lic. #H0810890000 M1 windowking1075@aoLcom
ustomer's Name: 1 (,IU6
tAddress: 1 t� #
1.
eleph e: Home{ �) 7
Work (—)
CONTRAGT OF SALE
j See Attached Addendum for Description of Work
otal Contract Price (includes Labor 8r Materials):
I AYMENT TERMS:
eposit �
Pon $ t
Pon Completion $ ''� 3� ( jam
!I NOTE: Perce
ntage figures shown above relate to work performed,Materials supplied,or contractor's profit or expenses
A l P ides Include: Options: ,
! ear Labcr Wanani Grid F attem:
,_.}'Y Y G�Fua 2 Bend Capping WANK CHECK
EC
l L1 oval of All Debris CJ fult 4 Berta Capping 0 NOfe � i� Vr Lr
i LOw E Glass 0 Top Only
Color
r>sids&put
gonGasFitted lTop8Batom O CREDIT CAI
Color 4i ew Interior hfolding Cl Contour D
anutacturersWananty Frosted Glass Fiat
Nit Included: ❑ New Stop h9olding
Removal or installation of curtains,shades or blinds Grid Patternsiti be (MUST BE GIVEN ON THE DAY OF JOB)
Installation of air conditioners or alarms sensors
Factory specs unless
POntutg of preparation for painting specified=-n Contract Customer's Initials:
-14141irgsof any sort of Sale. —
R mval of Gates
TiOn or City Permits are customers responsitdlity Approx, Delivery Time: weeks
P 191@tl (From Date of Measure)
P yment will be made as stated In this contract. if any portion of the prcr#sc#icrinnct I completed due to errors,umsicn car dQfec4ive rrtatera(s,€hNyef . I
may only withhold that anrrtur#t of rncrtey for the cost of tee itertts in question; ttyrirrdp*King t Lc 5},att not be held Liable for dais in
All sum,not paid wtivri due shall bear interest at the rat e of 1.?t,®s delays comixeting the;irk.
n less than 1/3 the oufstartdxrg balance shall be paid by Ilya customer�t 1h�rustr}mer fails atr�make payments as te it is due. AJ1 costs he�i tcProvided,yyy��o�Kin
y es of
m ti step work wilhriut prejudice to any other'f antedy he Wray have. 9 i
Any alteration or deviation from the above specifications involving extra costs will be executed only upon written and approved work orders!change
err o and will become an extra charge over and above the original subnutted estimate.
e sit to be held in Escrow for a period of Three(3)Days.
' on-payment will result in a lien on property,plus fetes.
' indow King,LLC is not responsible for any personal items left in home.
t H Ireby agree to the terms and conditions of this contract. I understand that this custom order cannot be cancelled after 3 business days. Cancellation
mul t be in writing and be received at the above address within:3 business days ofthe signaturefd6e be ow.
F
Pur�ehaser Dates ;'�_ ,
Wind King,LLC Representative Date
WINDO KING , L.L C
`W.C.LiC.#:15985-HO4 1075 Morris Par:kAveoue,Bronx,New Yo— k 10461
`N.Y.C.-OCA Lic.#:1171450
*Yonkers Lic.#:3979 1 a) 79 9
*C.I Lie.A0603035 .Specializing in: (718)239-0800
*Rockland Lic.#H-09683 [Mir�da►�s .Security Doors Toll-Free:(B�JU)433-9925
*New Jersey Lie,#1vtiva05590v ADDENDUM TO CONTRACT OF SALE Fax.(718) 792-6052
www.windoWking.biz
BETWEEN: WINDOW KING, LLC
AND / a
---------- _________ Email:
ATED: Y� _2,01
TELEPHONE:
REMISES: l>W
ESCRIPTION OF WORK: WINDOW REPLACEMENT --�-
* Remove the following listed windows:
_�. --______
--
i - —
* Su 1 and install the founwin listed�Idnws:
Mfg and series name:
4 f ) t
Amount and type: -------
Amount and type: �f
Color:
Glass:
Screen:
Colonialgrids: '(E
Energy � -.-
package R- 10
Yr dwelling built: Children under
Pregnant female: YEa
_...
FINAL CONTRACT INCLUDES:
Flerrlove all old window d biris
-- Can and caulk all new windows
EPA Certified HencXator
WINS KING LLC
B Y— ILLLL
(Contractor) BY--_
(Customer)
"WE LEtGFi ORIV� 0RA TO��IFS
`YORK.P-rJNSYLVAMA 17406
T=IcPHChlE(i 17)846-12Qp
FAY(717)767-41 Cx)
S7'RUCTtJRA.L P.8R �n^rw.nc!6rc.co,r.
FOlflM NCE TESTREPORT
Report t'110: NCTL-110-12109-1
Test Date: 04/30109
Report Date: 05/18i 09
F-Viration.Date.• 04/30/1'3
Client: Okna ,Windows
5601 Beaver Dana Road.
Bristol, P.11 19007
Test SFecimen: Okna Windows'Series "S 420» ,ype Isar ixontal Sliding
Vnyl Pr7nce
Mndou,'HS•R35 1600.2 x 2117,6(63x44).
Test S,uecifacatiora: AA111AtU'DMAICSA 107/1.S,21A440 0:5
Rtindows,Doors and Unit Sky Lights." , "StandardlSpecifxcalion,for
TEST SPECIMEN DESCRIPTION
General: The lest specirraera was a Ave X horzzorartcxl sliding'vinyl prirrae zvin
1600.2 nana(63')u%ide by 11171 6 nt.m(44')high, Bol.�a panels rrr.erxsrar ed 774.7
1009.65 nr.rn 39-3/�" dou rraeastaring
< 1)high curtly a clayligh.t.Opel7aTag'of 69g.5 mrrt - rranz(30.112')wi&-hy
3/4')high.. One(I)metal carry-type sweep Lock was located at .T58,75rnnr.
7 1/2') (vide by 933.45 nrrn(3G-
the interior meeting stiles. The metal kee Hers (,ere (6 114' front Positions.A rigid vi ti� 1 'located
on tlae exterior meeting stile aetathe lock ciz end of
i° n 1.filler teas Snap•fitted at the irOerlor and exterior•sill lrtacl�.'l 17?etul
roller/nylon hortsing Was located at 60.3,E rani �_'ror6nci plastic stoppers were fastened with one )scre'v ato7G.2 naTrz 13 of the bottor,a r'aalS. ��o lrcacks. (` )franc each end of tlae jar cb
Glazing: Both panels were exterior
bedding glazed using sealed glass urilh a foam trrlae back
b and asnap-an two(2)leaf rigid vrnyt.glazr.'n o g g
ryas X 9.U4 na.rn(3/4')consisting Of two(2)Net of double str eragtli.(3.I8 nzna(1/g" 1J '
+g bead. 7'17.e 0ver•a,l r'nstrlatingglass tlaicl,�raess
glass and on (1)space created by a thei-maplgstir.spacers Siena(2'P-D).
taclu t annacxle.d
WeaCherseals: One(1)strip of center fin weatherslr?ip(G8f nan7 (0.170" Jai r
jamb stiles brad exleriar meeting stile. Two 2 ) gla rt;as
Iazgh).u'er a localed al. the Perimeter of the fra are- Three(3)Str'ipsln/'cera�r�rrt�(6.86171112
�g6 rla�ap�ot.tlae
rrurl (0.270')were loetx(,ed at.the bottom and cob r bats.;One(1)34, ( �D')
nzna(0,39D'}laigla)was located at tlae interior t�rr exterior nzeeti e fin
uwajrstr rp(G:c46
,P of center fist weather Stria 1191
Weeps: one(1)(veep notch, measuring 69,85 rrr,rra( /4 Y ng stiles
errs,of the sill filler. nn.e(X)weep Iaole nzeasurx'
2 ') G'.35 nzna(1/4}teas located at each.
at each end of the interior and exterior si.l1. track. Onn(7)weep hold naeosla5 „
'dl.?5 nr.na (1 1I4)x 6,35 narra(1/.I,)tubs located
x 6 35 ram(1/19 ant,erral�loyin a
end orr'the exterior sill face. Chae(1)rl as"c Lep le MeasuriveeA ng$located
c t d at 32.5`'riar�(3-114'rrr (11. t4!
localNd at 4.76 nuu•(<3/.l�')franr each egad of tha botturta rails. )fr'ortr.eac.a
(1I4°)x 7(i ream
Interior$$xterior Sul face Finish: 1411aite billy,(PVC}
PROFESSION LS IN THE SC.IEPICE OF TESTI!E16
i
Okno. Windows
3of 3 I
Secttant:T NCTL-I10•r31t}9 1 '•
The glazing corners were sealed with ca silicone sealant.
hi
Insect Scr eert: An insect screen naeasur trag 74G 13 rram(19-3f3"
'glz was of mitered type corner constr•uctitrn with 3 )wide by 1009.6 rrtrrt(39-3/4'J
fiberglp naeslt cloth with a.Irollotu uin l s line Ond two Me keys. Me screen employed
Installation: The specimen was installed nto a standard(}larrtb rPtatrter springs.
lumber Zest back, Tlae specini.en tuns secured to the 9 a 19.05 ,In,, 3/ "
�•arle 50.8 ntnt(8')x 254 ntnt (ID°}Palling stop at the interior and exlerzor per ,peter. The ( 4} 1`3.05 rrant(314')
four(4)#8 x 41.28 rpm(1-518')screw on the iamb end parting stop
41,2 - �,
Iaearl and sill. The exterior perimeter was se is u;tth.a sto unxs secured to the Eru,cl�u,i!la
8 rrtnt (r ol8)screws al the
silicone sealant.
Pnr �To, TEST"SUf TS
-j-t-- the of Us etllod
5.,3.1.1 M�cl erl °
Operating Iorce Al
..�sr!r�Bona
Interior Faartel Initiate Open
Maintain Opon 40•03 N(91bf) -----
Initiate Close 10.08 N 69 lb f) 90 N(2tl lhJ)
Maintain Close
90'03 N(,91bf}
44.48_N(101bf) 90 11r r
L:eter for Farrel Initiate Open (-.0 Ffif)
maintain 53.38 N 02 lbf) -
e 40.03 N(9 lbf)
Initr.'ate Close `14 48N(IO lbf} 90 N(-90 lbl)
Maintain Close 53.38 Rr
.....
J.3.G.3 Del (121bf} 90 Rr(20 lbf}2 azraag.ns7Aj r:•)s;
Interior Panel
Top.trail.(230 N150 IN)
Bottom, Rail(280 N150 lbf) 8'6 U(1.09 natrtl0,043') <90%
Jamb Stile 6320 N/70lbf) 11.2%U.42 min/0.056",) <go%
Meeting Stile(320 ter/70)b 15.0%(1.91 ntntl0.075') <go%
16,6%(2.11 mnal0.0$3"} <go*/a Baterior Panel
Top Rail(230 N150 lbfj
13otto,a Rail(23o N150 lbf) 9-8%(1.25 rnm.10.pg9') 90�0
10
Jamb Stile(320 NJ70 lbf? -- %(1.3 m.17110.051') <90%
Meeting Stile(320 N/70 Ibf) 16.0%(2.03 in-m/0.0$0"} <90%
17.4%(2.21 nr)r./0.087") <90%
5.3., Air Infiltration
75 PO-(1.6 psf)(25 rrtpla}
0.5 L l(sec.nt) 1.5 L/
(<O.1 cf rr r.ft
' (sec.nt')
5.3.3 Wa.ter Penetratiort.,� / f r� (tJ3cfirrlft)
(0.01 ntLasured
3.4 L/ ntirt• saws 3.mr
( na}5.0 gph.1 fp
tVTP- 140 Pa (2.9 ps/)
5.3.1.2 x No Leal,:oge Ur dfor•m Load l�'o Leakage l3eflec:tiOn-.aSrai a�ci
720 Pa(15.0 psf)Exterior
720 Pa,(15.0 psj)Interior• 5.92 nr.na(0.2.93') ----
5.3.4.3 10.6 ntnt(0.417")
Uniform Load Structural.,jsrArt rsV
1080 Pa.(22.5 psf)Ir:�lerior
1080 Pa(22,5 psf}Interior 0.74 runt(0.029) 3.91 nun.(0:15<I"
0.31 rrurt(9•0X2") ,°.91 nxnz(0,15{J
Forced.F.nt)y Regis
tctrtce Test.
f+VU Fs.vr fbnrlr 1G 5.3.6.2 TherrMeetsets As Staled
rtopluslic Cor•raer fti`eld 7c st ,srm f,�ara
Meets:!s Stated
r�ytpnat� urraut�u Tara tsa.r:. zu2ro�dS p. c! ao?A
Ed"'�Ygcfaz H r.LYJ902t
un•:o?utlaaRE
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IJltir' o yzraszroo uatyi rar azl7 yrtozlJz(n 'ppazfr?ldaoxa aan o tda.r a
Isay.ro/pzca swMit)ar,fzoads partra.rafa.r az p p q you C2�ru 7.rlda.,srt
lr�nv rddt,paztzcr5o�ar.ro.ro v a tin cua� !l Y1?ar ayun77drrroa r uz t� 'spozl'latu
?1 paZotzparoa Aram sysay pIV
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p.! haul uo?rozr!?x.raa a Cq payuorffaq rCpuo�Cazu z!?rtlrn `yanpo.rd
pnno.rddo.to uvztatf?�caa a7rtYts� uoa 7ozr sa
rs Il n17 fo szror7nas. ayaJuasa.rda.r t I<r, fir. OP Y odas sx
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paoua.cafa.r az17.8trt.ta2p Siroaj'tparOJ ytlaY Syr J,roda.t StZly fO,Cdo: �r •7sanba.t•tiof!•rI
q T' '7�aYozr szrcrryvanap reuc� glzrli s•1z a14a1fo(? art;2ua7sa)
fo!!?q azl 'uo?pUo?fyrart paatl�ord.rof pamazrra.rar s,9rrtrttxi.tsaJ7Y�zro,I slvl.rayozu
at!'J to uaztrzaads?say azly oy patradzrro3 p•zca sr,ro�a.r,{royaragap.rah
p 7uazrocTzcro� 1,rodat szzly fo aurzy
am a14o??arra atanz s�ztzrrrrzr
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ro aayua rza3ag yozr swop pua ayaartoar�sr yutrt a as ,C 71 o�sux to papal 4anpo'id(CUD.C�ua.r.rvrn
pup o�tt?gsay o st?�J,tl'??°oI ysay azlr oy PUldz#ropy f,.co.td r ro cd uv? zu.rofzra!!a pzazl sazunssa pu,o
s?ada7 zuaoq 7say 0", 7 t�'LSV aqt ruo.ri trrrrat 'a o ,: 4 ysay azly Jo.tayazuz.tad
ro,iazynGapu a-t!�'u?p rn�a.r putt!rCua o sxrtrrsar 4 !aro uatutaads 1sa7 azlj ut s gay soy paJzrrtottr
st)n? uazut�arts ysay ar 1 ?• pz fo r�aonbapmi
!LL •tJ11po.cd pays al duos or11 1uarpa paurou ano o at rC
syarr o,td oI qJ O7 7o ?yua?rr s uvrxa�Yfroads trro.rq alp OM 01 parpdcfns
p ! ?ytraJrr.ro.raptturs fo {Jzpa}at, ay(l rC?a'vuz you o �p 11 pau'jyJ''alatunzu
raf a,ra s-7pnsa'i av •yaarpo.rrl sazlp fo 2toi�aar z p pu°paysay uaurzaads 13Jpg�zy,raa'atty
asrr a;r,rsztloxa at".co �. a�rt7?suoa yoil saa
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Building Permit Check List&Zoning Analysis C
Address: Z l �CZ. .sue (-1-'J L—) �S C SBL: l !q• y` —1 — l 3 r
Zone: v� Use: Const.Type: Other.
Submittal Date: - Z D Revisions Submittal Dates:
Applicant: D\A 3-7 AAA O )>_1 AF V
Nature of Work ln911J' t^j -T2R A GF— V—
Reviews:ZBA: J IJ1 — 7 209�PB: BOT: Other.
NE
OK
( ( ) FEES:Filing.=1�BP: L OJ. �inss C/O: I.egalizan:
( ) (�APP: Dated: / Notarized: ✓ S L 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 tamped: Sealed: Copies: Electronic: Other.
( ) (/ License: Workers Comp: ✓ Liability: omp.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 Plam: 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.
O O 20I7 NY State ECCC: N/A: Other.
( ) ( ) Final Survey Final Topo: RA/PE Sign-off Letter. As-Built Plans: Other.
( ) ( ) BP DENIAL LETTER: C/O DENIAL LETTER: Other.
( ) ( ) Other.
( )ARB mtg.date: approvaL• notes:
( )ZBA mtg.date: approvaL• notes:
( )PB mtg.date: approval• notes:
REQUIRED EXISTING PROPOSED NOTES APP _ 020
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AcaRly CERTIIFICATE OF LIABILITY INSURANCE
GATE(MMf00lYYYY)
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.T;4 S�11t2020
CERTIFICATE DOES NOT AFFIRMATIVELY E NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES
REPRESENTATIVE OR PRODUCER,AND THE CERTI NOT CCNSTITU RERS},TE A CONTRACT BETWEEN THE ISSUING INSU AUTHORIZEDFICATE HOLDER.
IMPORTANT; If the certfficate holder is an ADDITTIONAL 115 Ili ;D,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 endorsementis).
PRODUCER
N TP. LUAnn Silano
BNC Insurance Agency NAME:
PHONE (914)937-1230 FAX 80 South Ridge Street arC No Ext: (914)937-1124
ADDRESS: lsi \n pncagency.com (A/C No)Rye Brook INSURER(S)AFFORDING COVERAGE NAIC III
�____.__— __ NY 10573 Main Street Company
IN INSURER A: 29939
SURED
WINDOW KING LLC INSURER B.
1075 MORRIS PARKAVE INSURER C: "—
'" - INSURER D: -
BRONX INSURER E:
NY 10461-1,130 WN .I...F
COVERAGES CERTIFICATE NUMBER: CL1982893076
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED AB7 Els RN NE POLICY PERIOD
INDICATED NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT'OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN tS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS
LTR TYPE OF INSURANCE INSO WVD POLICY NUMBER LI�Q EFF� OLI Y P _
X COMMERCIAL GENERAL LIABILITY MM1DDlYY`ry MMIDpryY'YY LIMITS
CLAIMS-MADE a OCCUR EACHOCCURRENCE S 1,000,OOO
PREM;SES Ee occurrence) 500,000
A Y 8PU901 OZ LnEo EXP(Any one person) S 10,000
09/01/2019 09/0112020 PERSONAL&AOVINJURY g 1,000,000
GC-N'L AGGREGATE LIMITAPPLIES PER.
POLICY PRO- �LOC GENERAL AGGREGATE g 2,0 ,000
J ECT
OTHER. PRODUCTS-COMPlOP AGG $ 2,000,000
AUTOMOBILE LIABILITY - 5
ANYAUTO COMBINED SINGLE LIMIT
E.
accident S 1,000,000
A OWNED SCHEDULED BODILY INJURY(per person, S
AUTOS ONLY AUTOS BPU9010Z 09i01i2019 09/O1
X HIRED NON-OWNED i2020 BODILY
INJURY(Per acdjent) S _—
AUTOS ONLY AUTOS ONLY PROPER AMAGE
_ Per ac^ident
UMBRELLA LIAR
OCCUR —
EXCESS LIAB CLAIMS-MADE EACH OCCURRENCE 5
DED RETENTION S AGGREGATE §
WORKERS COMPENSATION -----
I AND EMPLOYERS'LIABILITY PER OTH-
ANY PROPRIETMPARTNER/EXECUTIVE Y J N STATUTE ER
OFFICER/MEMBER EXCLUDED? ❑ N/A
NH) `------=
(Mandatory in E.L.EACHACCIDENT 5
If yeas,describe under - I DESCRIPTION OF OPERATIONS below E.L.DISEASE-EA EMPLOYEES -
E L DISE41SE-POLICY LIMIT 3 _
Di SCRIPTION OF OPERATIONS/LOCATIONS J VEHICLES(ACORD 10?,Additional Remarks Schetlule,may be atrach®d if mare space Is required)
village of Rye Brook is included as an additional insured when required under written Contract or Agreement.
I
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 Building Department ACCORDANCE WITH THE POLICY PROVISIONS.
938 King Street
AUTHORIZED REPRESENTATIVE
Rye Brook NY 101,73
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORDI5 ACORD CORPORATION. All rights reserved.
NEW Workers'
Yoax CERTIFICATE OF
STATE Compensation Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE
1 a.Legal Name&Address of Insured(use W street address only)
y 1 b.Business Telephone Number of Insured indow King LLC -- -
1075 Mortis Park Avenue ,(718)792"5989
Bronx,NY 10461
1c.NYS Unemployment Insurance Employer Registration Number of
(Insured
Work Location of Insured(Only required if coverage is specrficalty limited to
certain locations in New York State,i.e.,a Wrap-Up policy) 1 d.Federal Employer Identification Number of Insured or Social Security
Number
1200508624
t Name and Address of Entity Requesting Proof of Coverage r3b.
Name of Insurance Carrier --�
(Entity Being Listed as the Certificate Holder)
\rllage of Rye Brook Building Department n Street America Assurance Company
938 King Street
Rye Brook,NY 10573 Policy Number of Entity Listed in Box"I a"
WCU9451 K
3c.Policy effective period
9/1/2019 _ to 9/1/2020
3d.The Proprietor.Partners or Executive Officers are
Included.(Drily check box it all partners/officers included)
all excluded or certain partners/officers excluded.
This certifies that the insurance carrier indicated above in box"T'insures the business referenced above in box"1 a"for workers'
Compensation under the New York State Workers'Cornpensation Law. (To use this form,New York(NY)must be listed under item_3A
on the INFORMATION PAGE of the workers'compensation insufance policy), The Insurance Carrier or its licensed agent will send
Q.---
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 pol;cy 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 nct 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 oil 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 all 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: Paul Sohigian
(Print name of authorized representative or IicenseC agent of insurance carrier)
\:y
Approved by' 0en112020
(Signature) --
(Date)
Title: Principal
Telephone Number of authorized representative or licensed agent of insurance carrier: 974-937-1230
Please Note: Only insurance carriers and their licensed agents are authorized
authorized
to issue it. to issue Form C-105.2. Insurance brokers are NOT
-105.2 (9-17)
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