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HomeMy WebLinkAboutBP20-137PERMIT # GY/J ! DATE:ZW4& SECTION �/- BLOCK_L TYPE OF WORK JOB LOCATION & OWNER l 1l vn n inr4 gcvjiiP i/i CO # TCO # FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING FEE DATE , _. INSPECTION RECORp DATE INSP GAS C] RGH PLUMBING SPRINKLER ELECTRIC [jam LOW -VOLT C3 ALARM Cl AS BUILT C7 FINAL -3(p/-5e5 m M 4.d P11arr,� �j �r c>f/ S OTHER APPROVALS BOT PB ZBA OTHER _ VILLA( +, P RYE BROOK WESTCHES%*U COUNTY, NEW YORK .. NO: 22-039 Certif irate of ®rrupaurp This is to certify that JQ �, Ld YC� /�S(CJ ' e VQ' /a(J of, P 6 , / \h having duly filed an application on JUIV c2 3 20 2� requesting a Certificate of Occupancy for the premises known as, /0,�3 J�L4,SV V6 0 J , Rye Brook,NY, located in a�Zoning District and shown on the most current Tax Map as Section: 135. 44 Block: _J Lot: and having fully complied with the requirements of the Building Code and the Zoning Ordinance under Building Permit No. CKU—/ 7 , issued / �? 20,�2Q, 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:R— o n e— !"R f'Y)/ / Construction: V , for the following purposes: MMiznm rej--2Gyafiat--7 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 all be made,nor shall the building be moved from one location to another until a permit to accomplish such change has n btained from the Building Inspector. Building Inspector,Village of Rye Brook: l Date: MAR 1 6 ZOZZ D E C E� V E �p R t For office use only: BUILDI V7l k MENT PERM[T# -/37 JUL 2 3 2021 VILLAGE OF RYE 1'30PK ISSUED: -7-LZQ-a;Wo VILLAGE OF RYE BROOK 9 S KING STREET,RYE BROOK,T 1I. �YORK 10573 DATE: - 0 1 BUILDING DEPARTMENT (914)939-Q6fi8 . 4)939-5801 FEE: / PAID �aWvti� o or APPLICATION FOR CERTIFICATE OF OCCUPANCY9 CERTIFICATE OF COMPLIANCE, AND CERTIFICATION OF FINAL COSTS TO BE SUBMITTED ONLY UPON COMPLETION OF ALL WORK, AND PRIOR TO THE FINAL INSPECTION ►rrs►►sssrrwwrrr►►r►s►srr«r««rrrr►rs►►♦s►ssps«wtwrwrr►r►s►r►rrr►rrrrrtrssrp►rrrssgt►►srr►rrggr►►►r►►rs►rsrw►r►►ssrrqssr Address: 16 pj'i c'u' br6.11 y1 �cy Occupancy/Use: 'Fo'..^ Parcel M#: 135.44— 1 _c �;2 Zone: U Owner: A��l.(� VCkit'l. Address: 165 Gob, P.E./R.A.or Contractor: M Q-rm 1 Address: fi 6-02 S+l ar,2 RS4 MP,o'�-'5"-'j{ Person in responsible charge: &0 11 Vrk� 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: JOW Q� \)a(fj being duly swom,deposes and says that he/she resides at P- (Print Name of Applicant) (No.and tteet) in !�j q., 9 f as L ,in the County of Y VI'-3A u Q sty in the State of ,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:$ 2 0, 6 a<' f for the construction or alteration of: k,+-ore,- i M 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--s Sworn to before me this day \ , 20.9-\ day of , 20 Signature of Property Owner Signature of Applicant \,'�4 — Name of Property Owner Print Name of Applicant No Public Notary Public SHARI MELILLO Notary Public,State of New York No.01 ME6160063 s/z 1/l9 Dualified in Westchester County Commission Exoires January 29 20 7 �E BRC�� O� 2m '9a2 BUILDING DEPARTMENT ❑BUILDING INSPECTOR ASSISTANT 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 rybrook.org - - - - - - - - - -- - --- - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS :- I `"'DATE: PERMIT# ��/ ISSUE -)aZlvcT' BLOCK: LOT: LOCATION: ` (` 1OCCUPANCY: r ❑ VIOLATION NOTED THE WORK IS... Q ACCEPTED ❑ REJECTED/REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION y N� V �`PC�\� � • r. ` � ��. Gy,c �„��f ❑ NATURAL GAS ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER �yE BRC�j�. 1982 BUILDING DEPARTMENT ❑BUILDING INSPECTOR ASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK [nl'�cODE ENFORCEMENT OFFICER 938 KING STREET • RYE BROOK,NY 10573 (914) 939-0668 FAX (914) 939-5801 www.Uebrook.org - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS : \_ ` J DATE: PERMIT# ISSUE :-- - �+—'-t BLOCK: LOT: LOCATION: OCCUPANCY: e— ❑ 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 HER In O 1 .. N a e 04 o ao Z tn i' u M � w M t. M M O Z a o w v s � .. N as en 6m ` O O W U o c p4 z 0 w ate ^ 1�1 O y W N .; <z co G� A z woo M WIN w v O w INCV p c n w g7 (> ,_, oc �"� F•I � Gti �' '� F' � O O 0 g � U w Z c o96 6 < a .. c i p BUILDING DEPARTMENT VILLAGE OF RYE BROOK AUG 19 2021 938 KING STUET RYE BROOK, NY 10573 (914) -0669 VILLAGE OF RYE BROOK XN ww.!:yebtaok.orr BUILDING DEPARTMENT ELECTRICAL PERMIT APPLICATION Westchester County Mastery Electricians License Required ^ FOR OFFICE USE ONLY BP #: C;7O—/3 / Approval Date: AUG 1 loll Permit Fee: $^/,!!5 0`/— Approval Signature: Other: Disapproved: (fees are non-refundable) Application dated, 7 01k is hereby made to the Building Inspector of the Village of Rye Brook NY, for the issuance of a Permit to install and/or remove 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: 1�S p 5`� gr w tl Rd SBL: Zone: 2.Property Owner: c)aV GA y a l ckd Address: _�Q j" A]a`alb a(1 la t -Cb m Phone#: S47-1 'qSa'j a�q Cell#: email: 3.Master Electrician: Yrurl"VQ.y1 rw Address: SS tZy1+ nML A-\;t t bk 10S( a Lic.#: t;11 Phone#%444R-ilaq Cell#:Rb4AAO-S53q email: 00,01,C3 M Company Name: Address: S6 &rat 1 Pwt,OL<&n mo> 4.Proposed Electrical Work/Fixture Count: 1920%1"On 0q ba*mom 4-Kkm-A �eC�'1'lCpl b0_k1K1tbM! Ca (YVl ou"lc--, (6 Siu►kt , C41 ly 1hch CeceS G\ 1\0is LJFN*�' KXkrXt % C SW t, dA , C1l 6-►nc..h lC-t_', reused 0,4 (3� 41 G AOS I (l� AP ovaIty STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: ,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 for the legal owner and is duly authorized to make and file this application. (indicate architect.contractor.agrnt.ationeN etc t 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 R44*f 4 Sworn to before me this day of 20 day of Signature of Property Owner Signature of Applicant Print Name of Property Owner Pr nt ame of Applicant Notary Public Notary Public IRACEMA ALMEIDA NOTARY PUBLIC,STATE OF NEW YORK Registration No.01AL5002693 Qualified in Putnam County 8/I b 2021 My Commission Expires October 5,2022 Westchester Rockland Electrical Inspection Services, Inc. Phone: 914-347-3595 *DO NOT WRITE HERE-FOR OFFICE USE ONLY 43 North Lawn Avenue t=y F x�14-347-3596 Elmsford, NY 10523 BUILDING PERMIT NO. TEMP N DATE O} �17 CITY OR VILLAGE , ZIP CODE TOWNSHIP COUNTY STREET AN�NpIOCROA� \ O i ' ' _ POLE NUMBER BETWEEN WHAT TWO CROSS STREETS IS PREMISES LOCATED? SECTION BLOCK LOT OCCUPANT'S NAME a`'a 6 `v I a 'aa 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 2N°FL. 3�FL. R VILLA E OF E BR 0K REMARKS:LIST OTHER ELECTRICAL DEVICES NOT SET FORTH ABOVE-' �/ 1-!►)p„ i(�, '11�-,, rl\P�P1`5.11eVd 11 � �Ch+�, Ll ou*i 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❑ EXPOSED❑ CONCEALED❑ MUST ENTER APPLICANTS IDENTIFICATION NUMBER SERVICE ENTERS BUILDING OVERHEAD❑ UNDERGROUND❑ : - AVOID DELAYS BY GIVING FULL AND ACCURATE INFORMATION.ALL SPACE MUST BE FILLED IN OR APPLICATION MAYBE RETURNED. NAME OF COMPANY DATE OF APPLICATION SIGNATURE OF APPLICANT STREET ADDRESS TELEPHONE NO. a z �,2xNA-ra\ 1-i-4 ►�+- q� �� 9 CITY OR POST OFFICE /1C<I n`y ny Lf CODE LICENSE NO.WHEN APPLICABLE k--j WESTCHESTER ROCKLAND ELECTRICAL INSPECTION WRE10SERVICES'INC. BY THIS CERTIFICATE OF COMPLIANCE THE Westchester Rockland Electrical Inspection Services 43 North Lawn Ave, Elmsford, NY 10523 914-347-3595 (Office) 1 914-347-3596 (Fax) CERTIFIES THAT Upon the application of: Upon premises owned by: Fanning Electric Javad &Julie Valad 55 Central Avenue NY, Ossining 10562 Located at: 165 Betsy Brown Rd Rye Brook, NY 10573 Certificate Number: 1030609 Section: 135.44 Block: 1 Lot:22 BDC: Permit Number: EP:21-205-BP:20-137 A visual inspection of the electrical system at this premise described as a Residential occupancy,wherein the premises electrical system consisting of electrical devices and wiring,described below,located in/on the premises at: 165 Betsy Brown Rd Rye Brook,NY 10573 Basement T2 1st Floor 2nd Floor 3rd Floor L]Garage Attic Outside Other: Inspection was conducted in accordance with the NYS and NFPA 70-2017 International Electrical Code and detail of the installation,as set forth below,was found to be in compliance therewith on 09/13/21 Name Type Quantity Kitchen Reinspection-Kitchen ------- 1 Bathroom Reinspection-Bathroom ------- 1 This Certificate has been approved by Westchester Rockland Electrical Inspection Services. This certificate may not be altered in any way. , G� This certificate is valid for work performed before date of inspection only. isf=tc f t42444444414t4ato44-4 C C U 444144goo4#4444*A46#A44 4 F. r i OD ti ai C r4 O 0 ,O N c 0 I .� 16 Z v F ,L'i 2lk � Q ism, C/ ,Z� Z A4 �. .o v: v, < a O wrj ernco 920�*N vl� v Q O n rn rn z Z Z Q a zboo Z F _ yI � a, .. a �E [1RC��� D L� �"1 L� BUILDING DEPARTMENT SEP - 1 2020 VIL"A E OF RYE �OK 938 KltvgsCREET RYE B ,NY 10573 VILLAGE OF RYE BROOK (914)939' 939-5801 BUILDING DEPARTMENT wwWN or PLUMBING PERMIT APPLICATION (� FOR OFFICE USE ONLY BP 13 7 PP#: to / a-D Approval Date: SEP - 1 2020 Permit Fee: $1 / /- U Approval Signature: Other: Disapproved: (fees are non-refundable) Application dated, 1 Q0 is hereby made to the Building Inspector of the Village of Rye Brook NY, for the issuance of a Permit to install and/or remove Plumbing as per detailed statement described below.The applicant&property owner,by signing this document agree e that said plumbing work will be in conformance with all applicable Federal,State,County and Local Codes. /� 1.Address: / Ql g> -my 3"Voo SBL: • � Zone: R-10 2.Proposed Work: tmt6_74 ( s 3.Property Owner:J 0,0E VALAN& Address:1&S- Phone#: ? Y ? - 3Q -5792-,SCell#:, f7-31./ 2<' email 0 LCOO Q A147 Ce-11 4.Master Plumber:MA-f.Cy, qpIIAA{/q-4-A- Address: 6 4- AA Lic.#: Phoney#:��7- �"��b Cell#: lC \I email:`', �Pt�rn �Company Name: PL �ln� Address: 2 (�7 w�cQaAeOy) A `���( �4 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 t / / l st Floor 43 ' 2nd Floor 3 Floor 4 Floor 51'Floor Exterior 5.* List Other Equipment/Provide Details: (Notarized Signatures Required Next 2 Pages) 4- 3/21/19 STATE OF NEW.YORK,COUNTY OF WESTCHESTER ) as: u (X� being duly sworn,deposes and states that he/she is the applicant above named, (pr�in 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 before me this Sworn to before me this day of ,20 day of 20 St atwe of Property Owner ign ure App is . Print Name of Property Owner Print Name of�Pplicant Notary Public Notary Public This application must be properly completed in its entirety and must include 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 and/or not properly signed shall be deemed null and void and will be returned to the applicant. -2- 3/21/19 BUILDING DEPARTMENT D VILLAGE OF RYE BROOK FSE - 1 2020 938 KING STREET RYE BROOK,NY 10573 (914)939-0668 Fax(914)939-5801 VILLAGE OF RYE BROOK wvK>pV.ryebrook.orE BUILDING DEPARTMENT AFFIDAVIT OF COMPLIANCE VILLAGE CODE §216 • STORM 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 YORK, COUNTY OF WESTCHESTER ) as: x, Jv le V !"A. , residing at, RCTs� ( AJ (Print name) (Address where you live) 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; 667-75;E� jf�Lc�yJn) 6 PrIl , Rye Brook,NY. (Job Address) 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. - .-I . : - S (Si ture of Pro"Oer(,I)) I)Llc— VALE (Print Name of Property Owner(s)) Sworn to before me this day of , 20 (Notary Public) -3- 3/21/19 Building Permit Check List&Zoning Analysis Address: ! �� TS 0!�,,C2o SBL• Zone: o Use: Z Const.Type Other. Submittal Date: -1 I-ZL[ Revisions Submittal Dates: Applicant %,j A L 6� Nature of Work: Reviews:ZBA J U L 2 7 1019 PB BOT• Other. ( ( ) FEES:Filing: S- BP: l 'JO• ' 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: Copied 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. (vj" ( ) PLUMBING:Plans: Permit Nat Gas: LP Gas: N/A/: Other. Perm( ) ( ) FIRE SUPPRESSION:Plans: it 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. ( )ARB mtg.date: approval: notes: ( )ZBA mtg.date: approval: notes: ( )PB mtg.date: approval: notes: REOUIRED EXISTING PROPOSED NOTES APPROVED An& Date- JUL 2 9 7019 F � F� F� Main Co Accs•Co Ft H/Sb: Sd.H/Sb: spa: Tot.imp padd1w. Hag stories notes: U-Cl, CotiQR CV CO.CT • "EF'- V Z A EVIDENCE OF PROPERTY INSURANCE DATE 111.� II/12/2O 9 I THIS EVIDENCE OF PROPERTY INSURANCE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE ADDITIONAL INTEREST NAMED BELOW. THIS EVIDENCE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS EVIDENCE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE ADDITIONAL INTEREST. AGENCY �_ PHONE 718�. 383_-0306 ext. COMPANY � Marcin Luc Sterling Insurance Company Greenpoint Insurance Brokerage Corp 680 Manhattan Ave 182 Barnerville Rd Brooklyn New York 11222 Cobleskill New York 12043 Fvc No:(516)706-0206 ;DORless:insurance@greenpointbroker.com Phone: CODE: SUB CODE: Fax: AGENCY 1SO4 CUSTOMER I . INSURED LOAN NUMBER POLICY NUMBER Javad Valad,Julie Valad 3437698696 H040827ONY 165 Betsy Brown Rd EFFECTIVE DATE EXPIRATION DATE CONTINUED UNTIL 11/15/2019 11/15/2020 TERMINATED IF CHECKED Rye Brook New York 10573 THIS REPLACES PRIOR EVIDENCE DATED: PROPERTY INFORMATION LOCATION/DESCRIPTION 165 BETSY BROWN RD RYE BROOK NEW YORK NY 10573 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 EVIDENCE OF PROPERTY INSURANCE 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. COVERAGE INFORMATION COVERAGE IPERILS IFORMS _ AMOUNT OF INSURANCE DEDUCTIBLE Coverage A: Dwelling Replacement Cost 600,000 1,000 Coverage B: Other Structures 60,000' Coverage C: Personal Property 480,000 Coverage D: Loss of Use 180,000 Coverage E: Personal Liability 1,000,000 Coverage F: Medical Payments 5,000 REMARKS(including Special Conditions Premium of$2,070.00 is paid in full 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. ADDITIONAL INTEREST NAME AND ADDRESS X MORTGAGEE ADDITIONAL INSURED Quicken Loans ISAOA ATIMA LOSS PAYEE P.O.Box 1050 Woodword Ave LOAN# Detroit Michigan 48226 3437698696 AUTHORIZED REPRESENTATIVE ACORD 27(2009/12) ©1993-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Affidavit of Exemption to Show Specific Proof of Workers' Compensation Insuranc Coverage for a 1, 2, 3 or 4 Family, Owner-occupied Residence e "This form cannot be used 10 waive the workers'compensation rights or ob[igadons of arrY part%• 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 1 qu specific proof of workers' compensation insurance coverage for su h residenceying for, dbecauseo(pl aasec teockhtohe 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 o for which the building )performing all the work permit was issued or helping me perform such work. ❑ I have a homeowner's 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 a for all paid individuals on the jobsite) for work indicated on the building permit, or if appropriate, file a WC/DB-100 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 ho urs for all paid individuals on the jobsite)for work indicated on the building permit. (Signature of Homeowner) (Date Signed) = J I't I V,, i,d Home Telephone Number (Homeowner's Name Printed) Swerve to Isjsrs we tbt. � ,y,of Property Address that requires the building pemit: - �M enwq s SFi t nJt ■ Notary Public,State of f4ew York No.01 ME6160063 � O-3811'fed in Westchester County Commission Expires Jams* Puce an a c� ivied, this Form BP-1 serves as an exemption for both workers' compensation and disability beseiBts BP-1 (9-07) NY-WCB