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HomeMy WebLinkAboutBP20-197PERMIT # SECTION / TYPE OF WORK JOB LOCATION . OWNER yi t CONTRACTORQ EST. COST OV/CO # TCO # 1! VT" 0OLwfft:�O FEE 14.777751 .PW FEE &���DATE 3 FEE DATE INSPECTION RECORA FOOTI N G FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING Dd RGH PLUMBING/I GAS Zvi SPRINKLER ELECTRIC LOW -VOLT ALARM AS BUILT FINAL QG7, 17_fl pPa,_ow/ // u� MP� ao-14ALfi _c�Ie �Ielaoa3 �fPc ?l-/33f�74ullCoArfO�� OTHER APPROVALS ARB BOT PS ZBA OTHER FINISHED BASEMENT NOT APPROVED FOR USE AS A SEPARATE APARTMENT OR DWELLING UNIT -BUILT/FINAL S RVEY REQUIRED PRIOR TO I:INAL INSPECTION THIS BUILDING MUST BE POSTED YVITH A PERMANENT CONSTRUCTION TYPE IDENTIFICATION SIGN; v FR PRIOR TO THE ISSUANCE OF C/09 AS REQUIRED BY NY STATE UAW. 3 VILLAGE OF RYE BROOK WESTCHESTER COUN,,-"' , NEW YORK No: 23-089 �F12 Certificate of Occupancy KIihIs is to certify that `JlU &lie6yook Par-�nery of, k-1 / 7 having duly filed an application on // !C< (J 15, 20_C.??3 requesting a Certificate of Occupancy for the premises known as, ` Jat 2122/,�2 1e �C� , Rye Brook,NY, located in a UD Zoning District and shown on the most current Tax Map as Section: It,-,Q/•c;�5 Block: / Lot: 1. 54,a , and having fully complied with the requirements of the Building Code and the Zoning Ordinance under Building Permit No.c�O-" 9 7, issued QLJq 20 QO, 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: /\6 / Construction: —0 for the following purposes: n / 4 Subject to all the privileges, requirements, limitations, and conditions prescribed by law, and subject also to the following: FINISHED-BASEMEW NOT APPROVED FOR USE AS A SEPARATE APARTMENT DWELLING UNIT 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 s ade,' or shall the_building be moved from one location to another until a permit to accomplish such change h b obtaine om i ing Inspector. JUN 0 6 2013 Building Inspector,Village of Rye Brook: Date: QyE QR . 19 ti4 4.°uJJ v �tt � 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 June 6,2023 SC Rye Brook Partners LLC c/o Warjam Group LTD 4 West Red Oak Lane Suite 325 White Plains,New York 10604 Re: 12 Jasmine Lane, Rye Brook,New York 10573 Parcel ID#: 129.25-1-1.56 This document certifies that the work done under Mechanical Permit #21-133 issued on 9/17/2021 for the installation of a new gas furnace,a new condenser and related ductwork has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to QyE DR �y 19 t c�4.°JJ�v L 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 June 6,2023 SC Rye Brook Partners LLC c/o Warjam Group LTD 4 West Red Oak Lane Suite 325 White Plains,New York 10604 Re: 12 Jasmine Lane, Rye Brook,New York 10573 Parcel ID#: 129.25-1-1.56 Mechanical Permit#20-147 issued on 10/14/2020 for Fire Sprinkler System This certifies that the fire sprinkler system,installed under the above captioned permit,has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to D EC ENE -- DD �- `�t'.<<��� For office use nlv: BUILDIN ��3�FRTMENT PERMIT# - 9 7 MAY 15 2023 VILGAlbi OF RYE BIj6OK ISSUED:j_Q—/y—al0 9 8 KING STREE1t;y�YE BROOK, E— YORK 10573 DATE: VILLAGE OF RYE BROOK (914)93 , 06 1 939-5801 FEE: ,1$ PAID,$ BUILDING DEPARTMENT o or 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 ass►rsr+ss►►s►ss►sass:►u►+rs►rrsss►•ss►►►ssssra+►r►►rssrssasrss+a•♦ssas►sr►a►ssrrsssassssps••s►sr►r»sss►►ss+retspsr►p• Address: 12. -IPSrA r 1`4kL l.AT--S CA, B¢G»K. N y IA&: '3 — l c L I or �( I Occupancy/Use: "s Parcel ID#: 12q-26— I — ('54, Zone: P LL D Owner: SC e��� ,P,p►>eTN*e:S LLI✓ A d 1G rress: 4�k 2 GR 1-0 STD 325 lei r& 'PLA Al P.E./R.A.or Contractor: r t—1 " tiu�Loftkc4r Address: I'`"P .�- 1J 5 VJJA rQ Person in responsible charge: W(LL t F01 e11CN L 3 wN nt 1�' A dress: Application is hereby made and submitted to the Building Inspector of the Village of Rye Brook for the issuance ofa Certificate of Occupancy/Certificate of Compliance for the structure/construction/alteration herein mentioned in accordance with law: STATE OF NEW YOM COUNTY OF WESTCHESTER as: LO I "I.P(rn e l`L N L. being duly sworn,deposes and says that he/she resides at 3R W441i rAkzt 12 D (Prim Name of Applicant) (No.and Street) in —%�Tw a 0-0 ,in the County of �a I i�l 7 in the State of C that (City/Town'Village) he/she has supervised the work at the location indicated above,and that the actual total cost ofthe work,including all site improvements,labor, materials,scaffolding,fixed equipment,professional fees,and including the monetary value of any materials and labor which may have been donated gratis was:S 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 belie$the structure/work has been erected/completed in accordance with the approved plans and any amendments thereto except in so far as variations therefore have been legally authorized,and as erected/completed complies with the laws governing building construction.Deponent further understands that it shall be unlawful for an owner to use or permit the use of any building or premises or part thereof hereafter created,erected,changed,converted or enlarged,wholly or partly, in its use or structure until a Certificate of Occupancy or Certificate of Compliance shall have been duly issued by the Building Inspector as per §250-10.A.of the Code of the Village of Rye Brook. Sworn to before me this Sworn to before me this 1- day of , 20_g� day of Z % 120 .9,)— Lf Signature of Pro ner Signature of Applicant Lk3(LL-I.aKI M C4j t c 1tLNk—';S Ls I t.L I40'a" 2.1 k u LL Print Name of Property Owner Print Name of Applicant 42 , ly Al�'ry C�_ ` �� �^ — Notary Public d Notary Public v CkilftANO (illdodoe A 1layd Notary Public.Soft d lit►Yak Nay PoW Stole of Now York , ) No.OlSM166M No.01906166307 Qualified in Westchester County Qualified in Westchester County ommtssion Expires May 21,3Ww2C�„3 " F\hires May 21,?!W o20JL3 �yE BRC��. ,9a2 BUILDING DEPARTMENT OUILDING 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 :_ `" � �--`'� Q�C DATE. PERMIT# V ` ISSUED: SECT: BLOCK: LOT: LOCATION: -�'V ` ll� 1 I �1 J' OCCUPANCY: -�? ❑ Violation Noted THE WORK IS... PASSED ❑ FAILED REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ Natural Gas ❑ L.P. Gas S' ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION 0--FINAL ❑ OTHER QyE BR(�k• • 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 : �� ," " ` DATE: PERMIT# 2 `-' - t ISSUED: SECT:) U ' / c n , �S BLOCK: / LOT: J LOCATION: LJ� ��` — 1 OCCUPANCY: J ❑ VIOLATION NOTED THE WORK IS... .F.f ACCEPTED ❑ REJECTED/REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING 1\VV}A;?5 ❑ ROUGH FRAMING ❑ INSULATION ❑ NATURAL GAS ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER �yE BRC��. 1982 BUILDING DEPARTMENT ❑BB�UILDING INSPECTOR A ISTANT 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:— ` DATE: L PERMIT# f� v �l- 1 ISSUED: U �� CT:'A;E BLOCK: � LOT:I l " `) LOCATION: 1 OCCUPANCY: ,O ❑ VIOLATION NOTED THE WORK IS... 0 ACCEPTED ❑ REJECTED/ REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION 1 1 ❑ NATURAL GAS T V C O `L ❑ L.P.GAS `f Gni U ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER QyE BR(��, QJ>/� •��O•c '9a2 BUILDING DEPARTMENT ❑BUILDING INSPECTOR ,, __,,'ASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK /El CODE ENFORCEMENT OFFICER 938 KING STREET - RYE BROOK,NY 10573 (914) 939-0668 FAX (914) 939-5801 www.ryebrook.org - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - -- - - - - - - - - - - - - J ADDRESS :— �:`J30.J DATE: n ` an Cj PERMIT#0 1" ISSUED: ` CT: BLOCK: LOT: LOCATION: OCCUPANCY: 2 ❑ VIOLATION NOTED THE WORK IS... ❑ ACCEPTED ❑ REJECTED/REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑'ROUGH PLUMBING ;fQ ROUGH FRAMING ❑ INSULATION [3 NATURAL GAS ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER d ncn � $ 2 u K _ \ 0 co M -1 CZ 140� n % K & } \ .§ ? } \ 2 « 2 4 < o ) J \ co » } It d^ � b k 00 % CY WIZ & » z � 00 A •-_ k k k� � ~ Cd 0 `�7 � v cn u k 0 4 a 2 a a QyE BR(�k. .Fo 1982 BUILDING DEPARTMENT ❑BUILDING INSPECTOR 'ASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK /f3 CODE ENFORCEMENT OFFICER 938 KING STREET • RYE BROOK,NY 10573 (914) 939-0668 FAX (914) 939-5801 www aebrook.org - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS: DATE: PERMIT# Z�'` -\� ISSUED: SECT: i2 t,"Z�BLOCK: LOT: _X3- _W2 LOCATION: OCCUPANCY: Z ❑ VIOLATION NOTED THE WORK IS.. ACCEPTED ❑ REJECTED/ REINSPECTION ❑ SITE INSPECTIOON REQUIRED Z FOOTING C ^771-- << Q ❑ 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 woe BRC�k, 0. Z� cu � Q�i� •F, • �9°2 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 Uebrook.ors - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS : `� � DATE: 1-Z PERMIT# \ (�.� 1 ISSUED: �I SECT: BLOCK: LOT: LOCATION: � �\ L_ OCCUPANCY: Z( V ❑ VIOLATION NOTED THE WORK IS... 'g/ACCEPTE ❑ REJECTED/REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION 0- UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING �'��n! w , U ❑ ROUGH FRAMING ❑ INSULATION ❑ NATURAL GAS ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL OTHER �E BRa 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.Uebrook.org - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS :— J_t. a c A \ Lc� r 1�:' DATE: PERMIT# l `i' 1c�`� ISSUED: CT: BLOCK: LOT: << LOCATION: \Vt \ OCCUPANCY: U ❑ VIOLATION NOTED THE WORK IS... ACCEPTED ❑ REJECTED/REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE j ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION pp ❑ NATURAL GAS �C������Y �, ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FTAL �/I<YTHER QyE BRC��. w � • 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.ors - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - -- - - - - - ADDRESS:— DATE: 25 2 vn lJ���� Q I . rERMIT ISSUEI: SECTJ. BLOCK: LOT: LOCATION: OCCUPANCY: Z`'Q� ❑ 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 \V a, ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL a OTHER QyE l3RC�k. U,932--�6 BUILDING DEPARTMENT ❑BUILDING INSPECTOR ASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK /f ❑CODE ENFORCEMENT OFFICER 938 KING STREET • RYE BROOK,NY 10573 (914) 939-0668 FAX (914) 939-5801 www Uebrook.ore - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - -- - - - - - - - ADDRESS : DATE. ! PERMIT# ' ISSUED: `v��� ECT: 1 - `'BLOCK: - LOT: I` LOCATION: V � 1 ` OCCUPANCY: 21 ❑ 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 ❑ FINAL OTHER r O Z� cu � BR ��• 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.or¢ - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS :— a DATE: Z PERMIT# ' 2-JC)- 6� ISSUED:402Z.)SECT: VG . 'TcS BLOCK:LOT: 1 i LOCATION: 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 ^1 ` ❑ NATURAL GAS ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION FINAL OTHER r moor 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 : 1 DATE: PERMIT# 1 C ISSUED: SECT: r&-�BLOCK: LOT: ,mow LOCATION: �—` C� OCCUPANCY: 2 ❑ VIOLATION NOTED THE WORK IS... ACCEPTED ❑ REJECTED/REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ll' UNDERGROUND PLUMBING NOTES ON INSPECTION: 0 ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ NATURAL GAS ❑ L.P.GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER O� Zm Qf>/� •Fo 1932 BUILDING DEPARTMENT ❑BU_ILDING INSPECTOR I�IASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK ❑CODE ENFORCEMENT OFFICER 938 KING STREET • RYE BROOK,NY 10573 (914) 939-0668 FAX (914) 939-5801 www.aebrook.org - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS : ��1 N� �' ` `� DATE: PERMIT# U- ISSUED: I O L( ECT: 2� c' LOCK: /LOT:' LOCATION: 6 �--�, OCCUPANCY: L ( U ❑ VIOLATION NOTED THE WORK IS...XAcCEPTED ❑ 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 ❑ FINAL P,�OOTHER QyE BRC�k. • �9�2 BUILDING DEPARTMENT ❑BUILDING INSPECTOR DASSISTANT 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 : �' �'�, �� O 1 ` y` �- DATE: z r �P PERMIT# Y ZO^ ' ISSUED: SECT: BLOCK: LOT: LOCATION: �1C_�` , -� = OCCUPANCY: ��\ ❑ VIOLATION NOTED THE WORK IS... ❑ ACCEPTED ❑ REJECTED/REINSPECTION ❑ SITE INSPECTION / REQUIRED ❑ FOOTING Q- FOOTING DRAINAGE � � -- b 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 QyE BRC�k. O� Zm • 1982 BUILDING DEPARTMENT ❑BUILDING INSPECTOR / 'A SSISTANT 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.or - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS :- ! /p� Q�) t 1'\ti Q DATE: PERMIT# ( ISSUED: r S� (`� SECT ` BLOCK: r LOT: i / LOCATION: OCCUPANCY: Z G ❑ 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 ❑ FINAL ❑ OTHER s f��'• 1982•��o BUILDING DEPARTMENT ❑BUILDING INSPECTOR � SSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK ]CODE ENFORC19MENT OFFICER 938 KING STREET . RYE BROOK,NY 10573 (914)939-0668 FAX (914)939-5801 www ryebrooLorg ----- - - - - - - - - - - -- - - - INSPECTION REPORT - - - -- - - - - - - - - - - - - - - - ADDRESS : Q DATE: �� PERMIT* V % ISSUED: ` �,1BCT: LOCK: LOT: L LOCATION: ` I:l V C 1 l \.?� OCCUPANCY: z--l�l ❑ VIOLATION NOTED THE WORK IS... ACCEPTED ❑ REJECTED/REINSPECTION ❑ ITE INSPECTION REQUIRED OOTING 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 r f r + ` N � N u r f wIQ ay x Lq ti NF.� O �_ v •� � . Ln r. ^ U0-4 W _ 1 u, ICQ v 8z i W , z • ~ � � � tx W U � O t Q r V c V ►-� z � � A N c ' �. z 4 ., r MM� � ~ (wj w w ^ramy`� o o z �• W � z w A N os oC U V * w O , Z0.4 w c off y2 z r z A O �- q a z w q oA H Q V W a 4 w x � J D BUILDING DEPARTMENT SEP 12 2022 VILLAGE OF RYE BROOK 938 KING STREET RYE BROOK,NY 10573 VILLAGE OF RYE BROOK (914)939-0668 BUILDING DEPARTMENT www.aebrook.org ELECTRICAL PERMIT APPLICATION Westchester County Master Electricians License Required FOR OFFICE USE ONLY BP#. 20-197 EP#: Approval Date: SEP Permit Fee: $ 5a 05d? Approval Signature: nw? Other: Application dated, 08-26-22 is hereby /;ina uilding Inspector of the Village of Rye Brook NY,for the issuance of a Permit to install and/or remove electrical equip eg,fixtures,or to perform other high or low voltage electrical work as per the detailed statement described below. By signing this document, the applicant & property owner agree that all electrical work performed will be in conformance with all applicable Federal,State,County and Local Codes. 1.Address: 12 Jasmine Lane SBL: 1 A -1-1 .560 Zone:BAD 2.Property Owner: SC Rye Rrnnk Partners Address:5 International Drive Phone#: 914-481-1.531 Cell#: email: 3.Master Electrician: Denis M. Fortino Address: PO Box 713 Rye, NY 10580 Lie.#: E-51 Phone#: Cell#: 914-760-5226 email:_dfortin ae, nterpriseeler coo Company Name: Enterprise Electrical Consulting Address: PO Box 713 Rye, NY 10580 4.Proposed Electrical Work/Fixture Count: Wiring for New House, Wiring for line voltage smoke detectors 5.3rd Party Electrical Inspection Agency: SW IS STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: 5 r A o>being duly swom,deposes and states that he/she is the applicant above named,and does further (print name of individual signing as the applicant) n state that(s)he is the legal owner of the property to which this application pertains,or that(s)he is the C/r n A for the legal owner and is duly authorized to make and file this application. (indicate architect,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 Sworn efore is day of 20 day f 2 L Signature of Property Owner Signature of Applicant Denis M. Fortino Print Name of Property Owner t Name of Applic t Notary Public Notary Public SHARI MEULLO Notary Public,State of New York No.OIME6160063 Qualified In Westchester County 6/23/2022 Commission Expires January 29,20 Z3 STATEWIDE INSPECTION SERVICES, INC. lit Main Street,Fishkill, NY 12524 1 emoil:office@swisny.com SWIS JOBAPPLICATION tel845.202.7224 • • 1• • • • Office Use Elect.Permit# Date Bldg Permit# Utility ID# Final Certificate# City Village 1� Zip - r• Township County ;'` Address S �,- y� / ,�� Cross Stfeet Section-,, Block Lott .. J Owner Name/Address(If different than above) '�,� ri f7�� f ; Contact Number ❑Basement [:}I st FI. ❑12nd FL ❑3rd FI. ❑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 i 1 E 12 2022 ! VILLAGE OF RYE BROOK BUILDING DEPARTMENT This application is valid for one(1)year from the date received by WAS.This application Is intended to cover the above listed Items to be inspected,If at any time of inspection additional Rom 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 for the above address with any other inspecton 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# Y � / Company Name i��/ i !_ �>^ Date Signature Address City/State �/ �' Zip Code License# Phone# DState Wide Inspection Services 1080 Main Street MAY 12 2023 3D Fishkill, NY 12524 845 202-7224 Phone VILLAGE OF RYE BROOK 914-219-1 Fax STATE WIDE INSPECTION SERVICES Email: office@swisnysny.com BUILDING DEPARTMENT Website: www.swisny.com Service With Integrity BY THIS CERTIFICATE OF COMPLIANCE STATE WIDE INSPECTION SERVICES CERTIFIES THAT: Upon the application of: Upon Premises Owned by: Enterprise Electric Corp. SC Rye Brook Partners LLC PO Box 713 12 Jasmine Lane Rye, NY 10580 Rye Brook, NY 10573 Located at: 12 Jasmine Lane, Rye Brook, NY 10573 Section: Block: Lot: Electrical Permit Number: EP 22-224 129.25 � 1.56 Certificate Number: 2023-2977 Building Permit Number: BP 20-197 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: 12 Jasmine Lane, Rye Brook, NY 10573 The Basement, First Floor,Second Floor,Attic, and Garage 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 26th day of April 2023. Name Quantity Rating Circuit Type Receptacles 73 Receptacle 01 20AMP GFCI 16 Switches 48 Dimmers 18 Smoke Detectors 03 C/O Smoke Detectors 05 Hood 01 Range 01 Dishwasher 01 Refrigerator 01 Disposal 01 Microwave 01 Name Quantity Rating Circuit Type Incandescent Luminaires 15 Recessed Luminaires 44 LV Under Cabinet Lights 03 HVAC System 01 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 �44toC; ;;t;O t t,U4&44449444to41;to4;4;f:414; 4141 �C.0 tuPA44 r • N ` O � O N = 1 � N O Q f 7 C lot96 � FEW r go i 5 i x Q-5 Q < 0. PLO �. co % CO U 07 ar W Z LLINow �° Z M � ;j' Gar.' t, roo;, f F w 4 o? < z Q U Q cQ r BUILII)N DEPARTMENT VILLAGE OF RYEf- ,. OK 938 KING STJtEET RYE BROOK, NY 10573 DEC 3 0 2020 (914)939'0668 FAx'.ffT 4)939-5801 www.twebiook.orR ELECTRICAL PERMIT APPLICATION Westches unty Master Electricians License Required /y FOR OFFICE USE ONLY U - ��-7 EP#: ��_ 0 Da Approval Date: — CNN Application Fee: $ Approval Signature: Permit Fee: $ '59 1 rt Disapproved: Other: (fees are non-refundable) Application dated, 1 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: I A -f65k`o/J4:5' SBL: / '1,25—1-1, 2Z Zone: P U O 2.Property Owner: SC Rye Brook Partners, LLC Address: 5 International Drive Suite 114 Rye Brook, NY 10573 Phone#: 914-481-1531 Cell#: email: 3.Master Electrician: Denis M. Fortino Address: PO Box 713 Rye, New York 10573 Lic.#: E-51 Phone#: 914-760-5226 Cell#: 914-760-5226 email: dfortino@enterpdseelec.com Company Name: Enterprise Electrical Consulting Address: PO Box 713 Rye, NY 10573 4.Proposed Electrical Work/Fixture Count: AYD STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: Denis M. Fortino .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 Electrical Contractor for the legal owner and is duly authorized to make and file this application. (indicate architect,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 Sworn to before me this 4-h day of ,20 day17-24�VA Signature of Property Owner Si mature of Applican D nis M. Fortino ���ttttllttu)n,,,� i Print Name of Property Owner Prin Name of Ap t ��`��<. . ....AA r '9i;G9 y Notary Public o ary Public O Co Np co N _ �N�� �0?2kPNTY' IVEI C O�',�`\\�. Westchester Rockland Electrical Inspection Services, Inc. Phone: 914-347-3595 DO NOT WRITE HERE-FOR OFFICE USE ONLY 43 North Lawn Avenue Fax: 914-347-3596, Elmsford, NY 10523 BUILDING PERMIT NO. TEMP# DATE /97 CITY OR VILLAGE ZIP CODE TOWNSHIP `+�iti COUNTY,_ STREET AND NO.OR ROAD ,. POLE NURAbER /72 <1 5 / BETWEEN WHAT TWO CROSS STREETS IS PREMISES LOCATED? SECTION BLOCIS 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 I� 1 BASEMENT 1"FL. 2�FL. VI t 3' FL. 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 IJ ADDITIONAL❑ EXPOSED❑ CONCEALED[j MUST ENTER APPLICANTS IDENTIFICATION NUMBER SERVICE ENTERS BUILDING OVERHEAD❑ UNDERGROUND❑ LLJ I I I I 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 ,y ter`�rli C�c_ X STREET ADPRESS TELEPHONE NO. C OR OFFICE ZIP LICENSE NO.NMEN APPLICABLE o M >x 9 ` w tnenh w a n a ° O ° ti M w ale 16 F- z o 1 W $ co a ~ A � w � �I °° 4 U O V a a w o � W O a C6 ° , ON zW �A.y M V w �CD ^ Z �� Oz A >en Zn _ m 00 r W a oc ON i z pq z pq z ° a d z .� N ; a e 2 � W e U 06, z 00 g c e N G7 � w V A pt BUILDIlY�DE�ART MENT ----- 3D — VILE/, OF RYE'BROOK MAY 25 2021 938KING R'/ <K,NY 10573 (914)93%0 68y ` e 5 939-5801 VILLAGE OF RYE BROOK www%r}�eb�oo .org BUILDING DEPARTMENT PLUMBING PERMIT A PPLICATION D - n7 PP#: DFOR OFFICE USE ONLY BP#: a Approval Date: MAY 2 5 2021 Permit Fee: $ V � Approval Signature: V. Other: Disapproved (fees are non-refundable) Application dated, 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 that said plumbing work will be1in-conformance with 1 applicable Federal,State,County and Local Codes. I.Address: la inn— Y1C 1T'f �) SBL:s��''/ —�- �• 5(D Zone: PU D 2.Proposed Work: ` <k ti } 3.Property Owner: Sc LrbrQoL Unas L LC Address: W(t A I o�qY Lit STE_''3 9.5 i T*' N'A i Phone#: q LA- 91600 Cell#: QIy" a 3N 'w6C email:A obais - LAK�P T Cbw[ 4.Master Plumber:' [A N,)& k. Address: Lic.#: 410 Phone#: (SLA -ES-1,W Cell#: t `email: �n 6 yTbLa_ LN DIuWtbcn4 •LnYn Company Name: 1 Prbfo►Sl/►i?,Umhma, myil 1 C CaO �ess: 10 R Ft �}M,�1�# I� ntoC��y ir 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 1st Floor ' r` 2nd Floor r] LA1 1 Id a "1 31 Floor 41 Floor 51 Floor Exterior n 5.* List Other Equipment/Provide Details: (Notarized Signatures Required Next 2 Pages) 00 1- \'0 3/21/19 STATE OF NEW YORle,COUNTY OF WESTCHESTER ) as: Pau 1 } �,,,, ,being duly sworn,deposes and states that he/she is the applicant above named, (print name of individual signing as t c 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 _cbyk-e'� for the legal owner and is duly authorized to make and file this application. (indicate architect,c(xtmetor,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. Swom to before me this -`3 ( * • Sworn to before me this day of du c ,20 _ day of 9LL4 t Ld/� ,20 ao Signatu f erty Owner Signatur of X11icant j.6 n L4.0c: t ' Pau 1 mebras iC Print Name of Property Owner Print Name of Applicant Notary Public A>�oyd Notary Pu i )l:ubic,Sintie'of NW York 4 , No.01906166307 in WaWbOter County Commbsiotn Fatptm' May 21,2W-2 0;�-3 This application must be properly completed in its entirety and must include the 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. WENDY J ABBAGUATO NOTARY PUBLIC-STATE OF NEW YORK No.01 AB6378708 Qualified In Orange County MY Commission Expires 07-30.2022 321/19 i • i � {� y � V € Q �• �• = o, = L o ` a IFM a• W E••i a .y �' 9 45 t r ~ �,go Ix 0 all E„y c oe vow �T w L(A ( A 6 �! = co plow 3 � M zNO < � V r OEM Lo. Q v gym .: it Now W6 uo f w ° F � 9 � EE N �% Fes- � Z J G p } •= � � e :7RFE� BUILD JNtt -dkARTMENT Li ( r U V VILL E OF RY OK 938 KING �� ET RYE BR 'NY 10573 AUG 2 5 2020 (914)939�468 (9� 39-5801 VILLAGE OF RYE BROOK BUILDING DEPARTMENT APPLICATION TO INSTAI,L FIRE SUPPRESSION / FIRE SPRINKLER SYSTEM FOR OFFICE USE ONLY: '] ell n— Approval Wtc: 9 �n�n 13P Z MP#: ow / / Application Fee:S OCTv Approval Signature: Permit Fees:$ _ Disapproved: Other: Application dated: _ is hereby made to the Building Inspector of the Village of Rye Brook NY lbr the issuanceofa l'ennit to install a Hre Suppression System as per detailed statement described below. I. Job Address: �.�,.;�, �,,.� Q�_ �"y___Parcel I.D.: IDQ,aS 1— 1.S6 Zone: I-LL 2. Proposed System(Describe system in detail including suppression agent): 13k9°cx,nlCle r 3u lcrr\ A-hrn u� _b" _ -- ------ 3. Number&Types of Fire Sprinkler Beads:E_ 4. N.Y State Construction Classification: 5B _N.Y.State Use Classification: 5. Cost of Installation:S /3',Tao (('ost shall include all labor.materials.fixed equipment.processional tees,and materials and labor which may be donated gratis.) G. Property Owner: _ broo Address:gQ q,���Cr--t- N N,W Phone# � {� r}�,-Sato Cell# _ email: Applicant: o1c0-ti.dr-\ _Address: ) l yr*rycDA BacK- Vtwc- M;cci�►Pk�ar��T Phone# b3 Cell#(%0 oemail:$9Z�rl�. Architect/lingineer: Q.W E!*nS-sX-knt- dress: �j19 Roar,9l cr SUTA_�0'l' P�a►en.t.►�, oat a9-«a-+ Phone# r l - Qua a2 Cell# email: General Contractor: �ur, �Zt� ��.ie to{�� � yAddress: L rn, r,nl LlvcrnuL_ NXI 3-, 56"� Phone#-84�,) Rn5-9406 Cell# fI email: -1- 12.8.16 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. Any application not properly completed in its entirety and/or not properly signed shall be deemed null and void and will be returned to the applicant. Please note that application fees are non-refundable. S'rATF.OF NEW YORK,COUNTY OF WFSTCHESTt:R ) as: �6e in-y%Ae— ,being 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 MA&& L &- _ Q7#4eadiori 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 confonnance 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 belbre me this Sworn to belbre me this day of , 20 day of t , 20 1 Signature of Property Owner Signature of Applicantl,I Print Name of Property Owner Print Name of Applicant Notary Public Notary Public Ir MICHAEL SILVA NOTARY PUBLIC MY COMMISSION EXPIRES OCT.31,2022 12 8 Ili C" C9 s cVW1 = � ►. O �� �j a. mom0 r �i U ry Al IF O ti 0ge `o z C%*A d o � tAco F* V P6, r" T rh F" 00 .. W '1 �,Uro ° Poo U Z U �V �a, E3wV C. u ob 0 (> cn e e+' z u •� E � � CL r4 E 9 ,E ,�ju , ,,y a w V p` } •= � � � �I CO Z a C = o BUILD_kNf:6 rRTMENT p E E Q VILE, E OF RY_�' OK 3D 938 KING 9- ET RYE BRdo'K_ ,NY 10573 SEP 14 2021 (914)91 9 39-5801 VILLAGE OF RYE BROOK :o .or BUILDING DEPARTMENT APPLICATION FOR PERMIT TO INSTALL AND/OR REMOVE HEATING, VENTILATION AND/OR AIR CONDITIONING EQUIPMENT FOR OFFICE USE ONLY: PI:RMI"I #: PP o'?I-13 Approval Date: SEP 17 2021 Permit Fee: $ o —Ab Approval Signature: Other: Disapproved: (fees are non-refundable) REQUIREMENTS FOR RELEASE OF PERMIT&CERTIFICATE OF COMPLIANCE: 1. Properly completed& Signed Application. 2. Site/Staging Plan if Required by the Building Inspector. 3. Copy of Licensed Contractor s Liability Insurance. (Village of Rye Brook must be listed as certificate holder)&Workers Compensation Insurance on a NYS Board form(Form#C 105.2 or Form#U26.3/or NY State Workers Compensation Waiver) 4. Payment of Fees/Unit: RESIDENTIAL=$100.00/unit COMMERCIAL=$350.00/unit. 5. Inspection by the Building Department for removal and/or installation.(48 hour notice required 6. Electrical work'requires a separate Electrical Permit&Electrical Inspection. 7. Plumbing/Gas work requires a separate Plumbing Permit&Plumbing Inspection. Application dated, q f t �30a2 1 is hereby made to the Building Inspector of the Village of Rye Brook for a permit for the installation and or removal of the HVAC equipment as listed below.The applicant and property owner,by signing this document agrees that said equipment will be installed and/or removed in conformance with all applicable Local,County,State&Federal laws,codes,rules and regulations. �y, 1. Address: S t n C Qn SBL: Id S-/-1,J�one: K' 2. Property Owner: S C R K0 D L L C Address: Phone#: Cell#: email: 3. Contractor: -T6 Address: a 6,0 9 3 Phone#: ?- to '70 b Cell#: email: lf'Vknc I v6�_N✓C• Q (Q. ror 4. Applicant: t I A r1c • O 'a Address: Phone#: a-b-31 1?11f- F-1.j 3 Cell#: email: 5. Scope of Work:New Installation(/g. Replacement( ) Removal( ) Other( ): 6. List Equipment: G U r A 4 6 7. Location of Equipment: �A(t M.,. 8. Method of Installation/Removal(list an equipment nettled to perf, GIB five )y , 1 3/21/19 STATE OF NEW YOM COUNTY OF ) as: ni1,A A 4 wr 1�—D ,being duly sworn,deposes and states that he/she is the applicant above named, (prilft name o 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 -Trt\,--,i Oriv-Ce/-- 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� Signature of Property Owner Signature 6RPplicant Print Name of Property Owner Print Name o Applicant Notary Public N W-AHAN D MASTROENI Notary Public- State of New York NO. 01 MA6267509 Qualified in Dutchess County My Commission Expires This application must be properly completed in its entirety and must include the notarize signature(s) of the legal owner(s) of the subject property, and the applicant of record in the spaces provided. Any application 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 N9MSE Product Specifications HEATING& COOLING PRODUCTS LIE to 96% AFUE, Single Stage, PSC Gas Furnace EA IER TO SELL • Up to 96%AFUE in upflow and horizontal positions, --- Up to 95%AFUE in downflow positions • Cabinet air leakage less than 2.0%at 1.0 in.W.C. and cabinet air leakage less than 1.4%at 0.5 in.W.0 when tested in accordance with ASHRAE standard 193 • Approved for Twinning applications(0601410 through 1202420) with accessory(order separately) • Approved for Manufactured Housing/Mobile Home applications (0401410 through 1202420)with accessory (order separately) • Low NOx units are designed for California installations and meet 40 ng/J NOx emissions. Can be installed in air quality management districts with a 40 ng/J NOx emissions requirement. TOUGHER • Flame roll-out sensors standard • Adjustable heating blower OFF delay • Factory set blower ON delay • RPJ" primary heat exchanger • Stainless steel secondary heat exchanger Illustrations and photographs are only representairve • High temperature limit control prevents overheating Some product models may vary. • Direct ignition with Silicon Nitride ignitor iHi h ual' corrosion-resistant, prepainted steel cabinet t . • AI�R TO INSTALL AND SERVICE • Direct vent(2-pipe), single-pipe venting or ventilated combustion Failure to follow this warning could result in personal injury, air death,and/or property damage. • 24 VAC humidifier terminal&electronic air cleaner terminal This fumace is not designed for use in recrea0on vehicles or • 35"(889mm) high,for ease of installation outdoors. This fumace is designed for use in manufactured • Simplified,factory installed internal condensate drain system (Mobile)homes when an optional Mobile Home accessory kit Is • Innovative knobs for easydoor removal and secure installed. attachment Failure to follow this warning could result in personal injury • Factory shipped for natural gas,with propane death,and/or property damage. gas conversion kits available • Four position- upflow/downflow/horizontal (left/right) installation °E s t s y • At least twelve different venting configurations • Through the casing flue pipe for counterflow or horizontal ARJO applications with accessory(order separately) t"•"r""" a"F"""l • Concentric vent available TMS JWL • Self diagnostics with super bright LED A] • Slide out heat exchanger and blower assembly LIMITED WARRANTY* rew an W% 97% • 20 heat exchanger limited warranty • 5 year parts limited warranty - With timely registration, an additional 5 year parts limited ,#111 CERTIFIED warranty * For residential applications only. See warranty certificate for complete details and restrictions, including warranty coverage for Uaa of Its AMRI C.roh.a TM Marts,gym manutacturera wtcom n the program ror other applications. vx hcatan or rare kab-f,r,y,,,a,al wo&, go to. avldww«,ag Efficiency AFUE Cooling Capacity Input CFM range Dimensions H x W x D Shipping Wt. Model Number (MBTUH) Upflow/Hz Downflow (0.5 in.w.c.(125 Pa) Inches(Millimeters) Lbs(Kg) N9 0261408 40,000 96.0% 95,0% 400-775 35 x 14-3116 x 1 x 361 x 120(54) 9 0401410 ,000 96.0 95 0% 625-905 759 x t 1 x 1 z 361 x t 23 9 040171 ,000 96.096 95.0% 650-1050 35 x 1 - x 1 889 x 445 x 750 N9MSED601410A 60.000 9 9 .0 6 5-1130 35 x / x 1 (889 x 361 x ) 127(57) N9MSE0601714A 60,000 96.0 95 0% 650-1420 35 x 1 -1 x -1 (889 x 445 x 7 144 65) NgMSE0801 80.000 96.0% 95.0% 10-16 x 1 -1/2 x -1 Tf(889 x x 750) 154(69) N9 S 0802120A 80,000 96.0% 95.0% 1335-1970 35 x 21 x -1/2(889 x 533 x 750) 162(73) N9MSE1002114A 100. 00 96. 9 915-1545 35 x 21 x -1/2 889 x 533 x 750 169 76) N9MSE I002120 100. 000 96.0% 95.0 1345-2065 5 x 1 x 29-1/2( 89 x 533 x 750) 169(76) 9 1202420A 120.000 96.0% 95. 1320-2105 35 x -1 x -1 x 622 x 79W 186(84) -N-9VS7-1402420A 1 140.000 96.0% 94.4% 1 1290- 035 35 x 4-1 2 x 29-1 889 x 622 x 7 1 90(86) Speciicabona are subieat to change rrtnout notice. 440 11 4403 05 12/3/18 I NXA6 ' . Performance Series HEATING& COOLING PRODUCTS Product Specifications HIGH EFFICIENCY 16 SEER AIR CONDITIONER ENVIRONMENTALLY BALANCED R-410A REFRIGERANT 11/2 THRU 5 TONS SPLIT SYSTEM 208 / 230 Volt, 1-phase, 60 Hz REFRIGERATION CIRCUIT • Scroll compressors on select models • Filter-Drier supplied with every unit for field Installation •Copper tube/aluminum fin coil EASY TO INSTALL AND SERVICE • Easy Access service valves on all models • External high and low refrigerant service ports • Only two screws to access control panel • Factory charged with R-410A refrigerant BUILT TO LAST • Baked-on powder coat finish over galvanized steel • Post-painted (black) coil fins • Coated, weather-resistant cabinet screws • Coated inlet grille with 3/8" (10mm) spacing for extra protection LIMITED WARRANTY* r, Th6 E�hasT to ENERGY �� • 5 year compressor limited warranty , r" chw Yon ap roprm" oo d 1:7;m_ "o proper relhgnant aterga and am erc Sow are o+acal • to actw,e rated cap" and ajowvV, hftwbm ot year parts limited warranty (including compressor and ma prong sr,o«,td fdloo,ure"w%jt@Mms reMrgera, COII) aYW� c�ar9n9 and air flow&M vstn y ortsred Fedora to aw" ?oper Charge end eiMaw may rence ggyy el�ercy -With timely registration, an additional 5 year parts limited wid~on ogLvfT1ent`''e warranty (including compressor and coil) * For owner occupied, residential applications only. See warranty certificate for complete details and , U� US restrictions, including warranty for other applications. LISTED Use of the AHNI Certified TM Mark in*Cates manufacturer s partlopat,on n the proffam.For verrficatlm of cenificatlon for,navouat proauCls. go to w ahr4rectory orq Model Size Nominal Min. Circuit Max. Fuse Operating Dimensions Ship/Operating Number (tons) BTU/hr Ampacity or Breaker height x width x depth In. (mm) Weight lbs.(kg) NXA618GKA 1 18,000 11.8 20 28-11/16 x 25-3/4 x 25-3/4 154/ 125 (729 x 654 x 654) (70/57) NXA624GKA 2 24,000 17.7 30 28-5/16 x 31-3,116 x 31-3/16 147/ 183 (719 x 792 x 792) (83/67) NXA630GKA 2 30,000 16.8 25 32-5/16 x 31-3116 x 31-3/16 188/ 153 (821 x 792 x 792) (85/69) NXA636GKB 3 36,000 17.5 30 28-5/16 x 35 x 35 204/ 165 (719 x 889 x 889) (93/75) NXA642GKA 3,/, 42,000 23.6 40 39-1/8 x 35 x 35 254/213 (994 x 889 x 889) (115/96) NXA648GKA 4 48,000 26.1 40 39-1/8 x 35 x 35 317/264 (994 x 889 x 889) (144/ 120) NXA660GKB 5 60.000 32.4 50 45-11/16 x 35 x 35 318/280 (1161 x 889 x 889) (144/ 127) Soeofico0ons suged to change Mhout notice 421 11 6201 05 5/17/19 RE C�L� OMC�Westchestergovcorn UG 13 2021 VILLAGE OF RYE BROOK BUILDING DEPARTMENT George Latimer County Executive Sherlita amler,DID Commi;siuner of Health August 2, 2021 Russell Palucci, P.E. 140 Princeton Drive Shelton, CT 06484 RE: Log #: 13336-21-DCDA Application for Backflow Prevention Device Kingfield Development 12 Jasmine Lane Rye Brook Dear Mr. Palucci: The plans and specifications for the above project have been reviewed and approved by this office pursuant to the provisions of Chapter 873, Article VII, Section 873.707.1 of the Laws of Westchester and Section 5-1.31, Subpart 5-1, of Part 5 of the New York State Sanitary Code. A Certificate of Approval is attached. Form NYSDOH-1013 is to be utilized as a Request for Completed Works Approval. This form can be downloaded from the following link: https://health.westchestergov.com/images/stories/pdfs/crossconnection doh1013.pdf .. NYSDOH- 1013 consists of two parts: (A) the initial test of the device(s) by a certified backflow prevention device tester, and (B) a certification by a Professional Engineer or Registered Architect, licensed and registered in the State of New York that installation is in accordance with the approved plans. The completed NYSDOH-1013 must be sent to our Department within 45 days of installation of the device(s). This form can be emailed to DOH-BFlow(u-westchestergov.com . Res ectfully, AW Delroy Taylor, P.E. Assistant Commissioner Bureau of Environmental Quality DT/RB:pm cc: Jeff Dubois —SC Rye Brook Partners, LLC Frank McGlynn, Manager— Suez Water Michael Izzo, Bldg. Insp. — Rye Qrook File � OORECYE Department of Health 25 Moore Avenue Mount Kisco,NTY 10549 Telephone: (914)864-7296 Fax: (91 I)»I:3-IG1)1 NEW YORK STATE DEPARTMENT OF HEALTH CERTIFICATE OF APPROVAL FOR BACKFLOW PREVENTION DEVICES This approval is issued under the provisions of 10 NYCRR, Part 5, Section 5-1.31, and Chapter 873, Article VII, Section 873.707.1 of the Laws of Westchester County. Log No. 13336-21-DCDA Facility: Kingfield Development City, Village, Town: County: 12 Jasmine Lane Rye Brook WESTCHESTER Owner's Mailing Address: Jeff Dubois SC Rye Brook Partners LLC 4 West Red Oak Lane-Suite 325 White Plains, NY 10604 Physical Location of Backflow Prevention Device(s): Dog House Description of Device(s): One 1 — 2 inch Wilkins 950XLTDABF DCDA) Water Supplier: Suez Water Name Designated Representative: Frank McGlynn. Mailing Address: Zip: 10801 2525 Palmer Avenue, Suite 3, New Rochelle, NY Conditions of Approval: A. THAT the device(s) shall be installed within 90 days, and that within 45 days of installation the attached New York State Department of Health Form DOH-1013 shall be completed and returned to the water supplier and the Westchester County Department of Health. B. THAT a certified backflow prevention device tester test the above backflow prevention device(s) at least yearly and report the results to the water purveyor indicated above. C. THAT any connection made prior to the backflow prevention device(s) shall render this approval void. D. THAT the proposed works be constructed in conformance with plans and specifications approved this day and any amendments thereto. E. THAT certification that installation of device(s) is in accordance with the approved plans, Form NYSDOH-1013, Part B,,must be completed by a Professional Engineer or Registered Architect,niCt,t, licensed anu registered ii� the State of New York. F. THAT the approved device(s) shall be so set that the test cocks are faced for easy access. G. THAT if facility construction has not commenced within 90 days of the issuance of this Certificate of Approval, then this Certificate shall become null and void unless an extension to the 90 day installation period is secured from the Westchester County Department of Health by the facility owner. Designated Representative ISSUED FOR THE STATE COMMISSIONER OF HEALTH BY: 09��q) DATE: August 2, 2021 Delroy Taylor, P.E. Assistant Commissioner NEW YORK 3TAre OW AATMENT OF HFALTH era. ;410-ikN,- r��,,�,,,._, Report on Test ens! Maintenance =Mwe a';r.r sls:�-Cxn.na rw.s-iaom r r!tl Atbesy.14Y 112V of Backflow Prevention Device Please use a separate form For each deaicq. , For the year s&Q� �- Initial 9est•Co.Tdara 9nhro lb!-" =---� A�!nlJ3I tBs.•Cx7C'3r9?a,:A xYy O Pub(l:water Svooiy I _ Z Socc j A caw. �e.5lc lie �c Block UA - i Fa�iiry kez!e Y,,,, •71P 1LJ Lacabon x Oavica Address 14: Vt .0 M r p � ItA t +57 �Cam+ (� ttty I Device Manufacturer Type 0 RPz Model Size din inches) Serial Number Information ��,I k',n S DCV 953 XL Check Valve Nat ChadrYelwNe.2 DflCetentM Prn3su—Renur Line Pressure Yaffe Test Leaked Leaked 0 Opened at_ psitl �� �� Closed _closed tght_� G 5 0 '� LI III re drop across first check valve q M D Y 1.75 paid I Cj OMCrfbO mpeft and Repaired by sll11110f is Name U"d Lie# Date repaired: m m M D Y Farrel beat Closed tight Closed tight � Opened at psid Date S L� 3 Pressure drop across first ice) M D Y check valve paid Water Meter Ntmber I Meter Reading Type of Service;(check one) t 9 Domestic 9 Rre 9 Clhar Remarks(Describe deficwneiea:bypasses,outlets before the device.connections between the device and point d entry.rni"N a inadequate a"aps•etc) r� Gerdfication.This device meets, dose NOT meet,the requirements of an acceptable containme dNvice at the time of testing hereby cerify ihn toregang data to be correcf. 30(% VXe I a�l 3d VnN rtwa canisod Tester No. 6Wialke Date Proparby o3rttsns(or awnere agent)certification that test was perfumed: Print Name Tale ra Two"'Ic tie Certification that Installation Is in accordance with the approved plans. fro be compWod by the design engineer or amitlied yr water srwpllerJ I hereby vartiry that this Instatbib—is in accordance w 4h the approved plans: Name RUssell PaIUCCi Tine Engineer Deft J O Nye DOH License Number 78721-1 Phone(845 )337-6040 - -— Representing nine O U cns, OnSU Ingo ngtneers Describe a Address 140 Princeton Drive City Shelton State CT zip 06484 MAY 15 2023 Signature 0 one comp tad Dopy to ere era earl dcymnnent reprnsom-6 am ono cony Co vra ware Hotly owner and warns sup pgor rmmedi3taty if device falls�aa and ropeirs aanrwt:mmeduteiv be e.B U I LD I N G R F F RTK/FENT td �) p tmAY 12 Jasmine Lane Rye Brook NY 105735 2023 2015 IECC Energy VILLAGE OF RYE BROOK BUILDING DEPARTMENT nN/" Efficiency Certificate Insulation . Above-Grade Wall 19.00 Below-Grade Wall 14.00 Floor 30.00 Ceiling / Roof 38.00 Ductwork (unconditioned spaces): R8 Glass& Door Rating LI-Factor SHGC Window 0.29 0.30 Door 0.30 0.30 CoolingHeating& Heating System: Heil#N9MsF1oo 1 nA 95.5% Cooling System: Heil 4 Ton#NXa648GKA 16 SEER Water Heater: Model VSCE32 119R 119 Gallon Electric Name: Jobe Leonard Date: 2119119 Comments Envelope Leakage Test [E C 'y D Testing Company: Technician: MAY 15 2023 10 Name: Name: Jay M VILLAGE OF RYE BROOK Address: Credentials: BPI BuildingjW16W ENT Email: info@prochek.com Building Information: Customer Information: Project ID: 12 jasmine Ln Rye Brook Name: The Energy Conservatory Address: 12 Jasmine Ln Address: 12 Jasmine Ln Suite 160 Suite 160 Rye Brook, New York 10573 Rye Brook, New York 10573 Geo-Tag Data: Latitude: 41.048528 Phone: (612) 827-1117 Longitude: -73.693479 Email: info@energyconservatory.com Ti mesta m p: 2023-02-1511:17:22 Measured Leakage: 2.13 ACH50 Leakage Target: 3.00 ACH50 Compliance with Leakage Target: Pass Test ID: 5556 Purpose of Test: IECC 12/15 Env. Leakage Measured CFM50: 1,542.4 (+/-9.0%) Effective Leakage Area: 71.4 in Building Volume: 43,397.0 ft3 Enclosure Surface Area: 4,726.0 ft2 Coefficient (C): 92.9 (+/-43.2%) Exponent (n): 0.718 (+/- 0.123) Correlation Coefficient: 0.98553 Test Standard: ASTM E779 (single mode) Test Mode: Depressurize Test Characteristics: Pre Indoor Temp: 68 OF Post Indoor Temp: 68 OF Pre Outdoor Temp: 58 OF Post Outdoor Temp: 58 OF Altitude: 197.0 ft Time Average Period: 30 seconds Test Date and Time: 2023-02-1511:44:27 2000 • Depressurize • E 1 8 • @ 700 J 600 o, 500 c 400 m 300 200 4 5 6 7 8 910 20 30 40 50 60 70 Building Pressure(Pa) Envelope Leakage Test Test Readings: Target (Pa). Bldg-(Ea). Adj Bldg_ft). Fan (Pa). Flow (cfm). Config Baseline -5.3 -60.0 -58.0 -50.8 -73.2 1,541.2 Ring A -54.0 -56.6 -49.3 -74.1 1,550.6 Ring A -48.0 -52.6 -45.4 -76.4 1,574.6 Ring A -42.0 -49.6 -42.4 -65.0 1,454.6 Ring A -36.0 -43.0 -35.8 -50.9 1,290.9 Ring A -30.0 -34.1 -26.9 -30.6 1,005.8 Ring A -24.0 -33.1 -25.8 -20.9 829.8 Ring A -18.0 -15.5 -8.2 -57.2 450.2 Ring B Baseline -9.2 Test Equipment: Flow Device: Model 3 110V Fan Pressure Gauge: DG1000 Serial #: 6006 Calibration Date: 2020-07-01 Deviations from Standard: • The interval between building pressures is greater than 10 Pa. • Correlation coefficient is outside of normally accepted limits. Comments: Blower door Report by TEC Auto Test 1.9.0 (132), © 2023 The Energy Conservatory, Inc. Page 2 of 2 Building Permit Check List&Zoning Analysis Address: L Z SBL• 1 12 2-S_ Zones tom_Use 7i l o Const.Type`:� Other. Submittal Date: 2 I-L2 Revisions Submittal Dates: Applicant: S •G- 12 � r 4-It- Nature of Work: GK G �►�-� Reviews:ZBA: OCT 1 3 2020 pB. BOT: Other. NEFtD OK ( ( ) FEES:Filing. 75•ph. BP: l`j t 2 , �� C/O: �-- ( ) (�'APP: Dated: ✓ Notarized. ✓ SBL: --' Truss I.D. Cross Connection: H.O.A.: ( ) ( ) Scenic Roads: Steep Slopes: Wetlands: Storm Water Review: Street Opening. ( ) ( ) ENVIRO:Long. Short: Fees: N/A: ( ) ( ) SITE PLAN:Topo: Site Protection S/W Mgmt.: Tree Plan: Other. ( ) ( ) SURVEY:Dated Current: Archival: Sealed: Unacceptable: ( ) (�PLANS:Date Stamped Sealed ✓ Copies: 7-Electronic: Other. (•� ( ) License: Workers Comp: Liability Comp.Waiver. Other. ( ) ( ) CODE 753#: Dated N/A: HIGH-VOLTAGE ELECTRICAL:Plans: Permit: N/A Other. (CY ( ) LOW-VOLTAGE ELECTRICAL:Plans: Permit: N/A: Other. (.K ( ) FIRE ALARM/SMOKE DETECTORS:Plans: Permit I-W.I.C.:_Battery:_Other. PLUMBING Plans: Permit Nat. Gas: LP Gas: N/A/: Other. FIRE SUPPRESSION:Plans: Permit: N/A: Other. I-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: APPRUVW REQUIRED EXISTING PROPOSED NOTES OCT 1 3 2020 Aga. Circle Froze: Front: Front: Sides: Rear. Maui Cov Accs.Cov Ft.H Sb: Sd.H S a Tot, EC.Imp PA&W. Height/Stories: notes: Residential Building Permit Fee Work Sheet Permit#: Date Issued SBL: Zone: Address: Z .S V--, - C Property Owner&Contact Info: Job Description: For all new dwellings and for additions measuring 800 sq. ft. or more made to existing dwellings, the following fee schedule shall apply: (plus any alteration fees) Total Sq. Ft. (excluding basements)x $225.00 x $I5.00/$1,000.00 Basement Sq. Ft. x $65.00 x $15.00/$1,000.00 -------------------------------------------------------------------------------------------------------------------- New Construction Sq.Ft. • New Construction Cost • Building Permit Fee Basement= sq.ft. x $65.00 = $ (0Z.< x$I5.00/$I,000.00 = $ cGO -3$ I�t Fl. = 223 10-- sq. ft. x $225.00 =$0�j�, 5-5�. x$I5.00/$I,000.00 = $ Z 5-5-3, 2"d Fl. = l 6 q 3 sq. ft. x $225.00 = $ cl Z s� �! -Z x$I 5.00/$I,000.00= $ G33 Attic= 16- sq. E x $225.00 =$ x$I5.00/$1,000.00= $+ Total Ft. = �t 9• S9. 6 s E Total Cost= $ Total B.P.Fee= $ q 0 °Includes Attached Garage if Applicable. Total Amount Paid = $ Rr Total Amount Due= $ OCT 13 1010 Date: Signed: R CERTIFICATE OF LIABILITY INSURANCE 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 °1 certificate does not confer rights to the certificate holder in lieu of such endorsement(s). E PRODUCER CONTACT 0 Aon Risk Services Northeast, Inc. PHONE Boston MA office IAC.No (g66) 283-7122.Eat): (FAX (900) 363-0105 v 53 State street E-MAIL Suite 2201 ADDRESS O Boston MA 02109 USA INSURER(S)AFFORDING COVERAGE NAIL• INSURED INSURER A: Navigators Insurance Co 42307 SC Rye Brook Partners, LLC INSURERS: GuideCine National Insurance Company 14167 230 Park Ave. New York NY 10169 USA INSURERC: Starr Indemnity tL Liability Company 38318 INSURER D INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 570082993250 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. Limits shorn are as requosted LTR TYPE OF INSURANCE BISO WVD POLICY NUMBER MM DID YYV MM DOY LIMITS B X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S5,000,000 CLAIMS-MADE F OCCUR PREMISES Ea ooc mt. $100,000 MED EXP(Any one person) Excluded PERSONAL&ADV INJURY S5,000,000 ,S GEML AGGREGATE LIMITAPPLIES PER GENERAL AGGREGATE S5,000,000 PRO- of POLICY X JECT LOC PRODUCTS-COMPiOP AGG S5,000,6OO do OTHER AUTOMOBK,E LIMLrrY COMBINED SINGLE LIMB n ANY AUTO BODILY INJURY(Per person) Z SCHEULE OWNED AOSD BODILY INJURY(Per accident) y AUTOS ONLY PROPERTY DAMAGE HIREDAUTOS NON-OWNED U ONLY AUTOS ONLY IPer accident C UMBRELLA LIAR OCCUR 1000579693201 0 / O 1110112021 EACHOCCURRENCE U EXCESS LIAR CIAPAS-VADE AGGREGATE S5,000,000 DED I RETENTION WORKERS COMPENSATION AND PER STATUTE TH• EMPLOYERS'LIABILITY Y I N ANY PROPRIETOR I PARTNER EXECUTIVE E.L.EACH ACCIDENT OFFICERAEMBER EXCLUDED' N t A IIl morktimmydesor i 0"« E.L.DISEASE-EA EMPLOYEE DESCRIPTION OF OPERATIONS below E.L.DISEASE POLICY LIMIT DESCRIPTION OF OPERATIONS LOCATIONS VEHICLES(ACORD 101.Additional Remarks Schedule,may be attached It more apace Is required) T--J =J7 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE _ EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. village of Rye Brook AUTHORIZED REPRESENTATIVE 938 King Street -r Rye Brook NY 10573 USA (01988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016-03) The ACORD name and logo are registered marks of ACORD Certificate of Attestation of Exemption from New York State Workers' Compensation and/or Disability and Paid Family Leave Benefits Insurance Coverage **This 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 carver 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): Building Permit SC Rye Brook Partners,LLC From:The Village of Rye Brook NY 1100 King St Ste 114 Rye Brook,NY 10573-1057 PHONE:914-481-1531 FEIN:XXXXX6509 The location of where work will be performed is 110 King Street,Rye Brook,NY 10573. Estimated dates necessary to complete work associated with the building permit are from March 17,2020 to March 16,2021. The estimated dollar amount of project is over$100,000 Workers'Compensation Exemotion 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: Robert Dale 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.) 1,Janice Heusser,am the Office Assistant 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. 1 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 HERESignature: Date: ' /a 1 Z • o D Exemptiop C ` `to Number f A ?a v`d 2 Mar .20 i� NYS Worke ° naation Board CE-200 01/2018 A4CC)R"® CERTIFICATE OF LIABILITY INSURANCE DATE04/13 mYY' 4/,32020 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 ri hts to the certificate holder in lieu of such endorsements. PRODUCER CONTACT FEDERATED MUTUAL INSURANCE COMPANY NAME, HOME OFFICE: P.O. BOX 328 A CN No, EXt:888-333 4949 CLIENT CONTACT CENTER FAX No):507-446-4664 OWATONNA, MN 55060 E-MAIL CLIENTCONTACTCENTER FEDINS.COM INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:FEDERATED MUTUAL INSURANCE COMPANY 13935 INSURED 149-868-2 INSURER B:FEDERATED RESERVE INSURANCE COMPANY 16024 MACK FIRE PROTECTION INC INSURER C: 15 INDUSTRIAL PARK PL MIDDLETOWN,CT 06457-1501 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:466 REVISION NUMBER:0 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE DL SUBR pOLICV NUMBER POLICY EFF POLICY EXP LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000 CLAIMS-MADE ❑X OCCUR DAMAGE TO RENTED $100,000 PREMI ES Ea ocarrence MED EXP(Any one person) $10,000 B N N 6042334 05/11/2020 05/11/2021 PERSONAL&ADV INJURY $1,000,000 N`L AGGR 00 E LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,JECT 0 X POLICY PRO- ❑LOC PRODUCTS•COMPIOP AGC $2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $1,000,000 a accl e X ANY AUTO BODILY INJURY(Per person) OWNED AUTOS ONLY SCHEDULED B AUTOS N N 6042334 05/11/2020 05/11/2021 BODILY INJURY(Per accident) HIRED AUTOS ONLY N ONLY AUTOSNON-O ONL PROPERTY DAMAGE AUTOS P idrW X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $10,000,000 B EXCESS LIAB CLAIMS-MADE N N 6042337 05/11/2020 05/11/2021 AGGREGATE $10,000,000 DED RETENTION WORKERS COMPENSATION X PER STATUTE OTH- AND EMPLOYERS'LIABILITY Y y N ER ANY PROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT $1,000,000 A OFFICERIMEMBER EXCLUDED? NIA N 6042338 05/11/2020 05/11/2021 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 11 yes,describe under DESCRIPTION OF OPFRATIONS below E.L DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached it more space is required) RE: KINGSFIELD 1100 KINGS ST RYE BROOK NY CERTIFICATE HOLDER CANCELLATION 149-868-2 466 0 VILLAGE OF RYE BROOK NY BUILDING DEPARTMENT SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 938 KING ST THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN RYE BROOK,NY 10573-1226 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE /" O 1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD YORK Workers' CERTIFICATE OF STATE Compensation Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a. Legal Name 8 Address of Insured(use street address only) 1b.Business Telephone Number of Insured 860-632-8053 MACK FIRE PROTECTION INC 149-868-2 15 INDUSTRIAL PARK PL 1c. NYS Unemployment Insurance Employer Registration Number of MIDDLETOWN,CT 06457-1501 Insured Work Location of Insured(Only required if coverage is specifically limited to 1d. Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e.,a Wrap-Up Policy) Number 04-3814418 2. Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Federated Mutual Insurance Company Village of Rye Brook NY Building Department #466 938 King St 3b.Policy Number of Entity Listed in Box"1a" Rye Brook NY 10573-1226 6042338 3c Policy effective period 05/11/2020 to 05/11/2021 3d.The Proprietor,Partners or Executive Officers are included.(Only check box if all partners/officers included) OX all excluded or certain partners/officers excluded This certifies that the insurance carrier indicated above in box"3"insures the business referenced above in box 1a"for workers' compensation under the New York State Workers'Compensation Law. (To use this form,New York(NY) must be listed under Item 3A on the INFORMATION PAGE of the workers'compensation insurance policy). The Insurance Carrier or its licensed agent will send 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 policy 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. Th s certificate does not 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 on 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, 1 certify that I am an 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: Elizabeth Petersen (Print name of authorized representative or licensed agent of insurance carrier) Approved by: — Q1 � 04113/2020 (Signature) (Date) Title: Authorized Representative Telephone Number of authorized representative or licensed agent of insurance carrier: 888-333-4949 Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-105.2. Insurance brokers are NOT authorized to issue it. C-105.2 (9-17) www.wcb.ny.gov A6O d DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 1/21/2021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CUNTACT AME OTT AGENCY PHONE FAX A/C No E.t (845) 895-8873 A/C No) PO Box 659 ADDRESS ottins2001@yahoo.com Wallkill, NY 12589 INSURER(S) AFFORDING COVERAGE NAICa INSURER Main Street America INSURED Total Comfort Inc INSURER B National Grange PO Box 359 INSURER C National Grange 7 Ohara Rd INSURER D National Grange Milton, NY 12547 INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING ANY REQUIREMENT TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INSR LTR TYPE OF INSURANCE INSD wvD POLICY NUMBER (MM/DDIYYYY1 I MM/DD/YYYY LIMITS x COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1 000 000 CLAIMS-MADE �OCCUR PREMISES Ea occurrence $ 500 000 MPU7919F 1/21/2021 1/21/2022 MED EXP(Any one person) $ 10,000 A X X PERSONAL BADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 POLICY FX7 PRO- JECT F LOD PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER $ AUTOMOBILE LIABILITY COMBINED Ea ecadenl $ 1,000,000 ANYAUTO 1/21/2021 1/21/2022 BODILY INJURY(Per person) $ OWNED SCHEDULED B1U7 919F B AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED AUTOS ONLY AUTOS ONLY Per accident) $ $ UMBRELLA LIAB OCCUR D EXCESS LIAB CUU7919F 1/21/20211/21/2022 EACH OCCURRENCE $ 5,000,000 CLAIMS-MADE AGGREGATE $ 5,000,000 DED I I RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN 1/21/2021 1/21/2022 STATUTE ER ANY R C FFICER MEMBER EXCLUDED?ECUTIVE NIA WCU7 919E E L EACH ACCIDENT s 1,000,000 IMand,rory In NH) E L DISEASE-EA EMPLOYEE $ 10,573 I yes describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101 Additional Remarks Schedule may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION VILLAGE OF RYE BROOK SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 938 KING STREET ACCORDANCE WITH THE POLICY PROVISIONS RYE BROOK NY 10573 AUTHORIZED REPRFSENTATI / 01988-2015 ACORD CORPORATION. All rights reserved. ACORD25(2016/03) The ACORD name and logo are registered marks of ACORD Yoaa Workers' CERTIFICATE OF STATE Compensation Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured TOTAL COMFORT INC 203-223-6700 PO BOX 359 7 OHARA RD 1c.NYS Unemployment Insurance Employer Registration Number of MILTON NY 12547 Insured Work Location of Insured(Only required if coverage is specifically limited to 1d. Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e.,a Wrap-Up Policy) Number 141829022 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) NATIONAL GRANGE VILLAGE OF RYE BROOK 938 KING ST 3b.Policy Number of Entity Listed in Box"1a" RYE BROOK NY 10573 WCU7919F 3c.Policy effective period 01/21/2021 to 01/21/2022 3d.The Proprietor.Partners or Executive Officers are ❑ included.(Only check box if all partners/officers included) XJ all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box"3"insures the business referenced above in box '1a"for workers' compensation under the New York State Workers'Compensation Law. (To use this form, New York(NY)must be listed under Item_3A on the INFORMATION PAGE of the workers'compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"2". Will the carrier notify the certificate holder within 10 days of a policy being cancelled for non-payment of premium or within 30 days if cancelled for any other reason or if the Insured is otherwise eliminated from the coverage indicated on this certificate prior to the end of the policy effective period? DYES ONO This certificate is issued as a matter of information only and confers no rights upon the certificate holder.This certificate does not 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 on 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 an 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: WILLIAM C OTT (Print name of authorized representative or licensed agent of insurance carrier) Approved by: (Signature) (Date) Title: PRESIDENT 1/21/2021 Telephone Number of authorized representative or licensed agent of insurance carrier: 845-895-8873 Please Note:Only insurance carriers and their licensed agents are authorized to issue Form C-105.2.Insurance brokers are NOT authorized to issue it. C-105.2 (9-15) www.wcb.ny.gov On 0 (D 7C, ar No X Z Z to w 0 =r l< > C: r fD CL 0 m ge; g, E t a as ff 0- 2: ID I a< 0 X fA m=r > Jo 0 ID ag x ck a co � la ;2. "o. W, m -0 2R21q, 2. lb 40 CL CL IS tLifvN cm, :L 's m - 0 CL 0 a, ID fD R zol ID 0 on ad Sw l< co m < M < w ch ..T y C3 a M rn -< in U) x Z rn U 0 m 3 O 04 -cam cl c M m nm M z In r.) T. m (n tn cAn -4 p m -M4 Z ul to m U 'a el Z3 z M z C3 > A Pz 0 > r-Opp rn X > z 0 > !q cli z a) M cli a > 0 a r, < z rn r- m )> M m x aTTI -0 r3 En in M O a z V � :I z M Cl .. 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