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HomeMy WebLinkAboutBP20-210IER APPROVALS PERMIT #IU/ SECTION TYPE OF WORK JOB LOCAT OWNER CONTRACTOR_ EST. COST vo/CO # U TCO # �) / 0 FEES EXP: lo LOT r , )�wjvex)3f 4slo,,o nk YO ,..s of o.o INSPECTION RECORD i DATE INSP FOOTING FOUNDATION FRAMING RGH FRAMING _ INSULATION PLUMBING__- RGH PLUMBING GAS SPR+NKLER ELECTRIC r LOW -VOLT ED ALARM ---- 01* AS BUILT 0 `� FINAL _.- N BOT P8 ZBA OTHER _ FINISHED BASEMENT NOT APPROVED FOR USE AS A SEPARATE APARTMENT OR DWELLING UNIT VILLAGE OF RYE BROOK WESTCHESTER COUNTY, NEW YORK NO: 22-036 Certificate of Occupancy This is to certify that -PC)0 /Q �7arcla of, k�C_ '/ d 0 k, y having duly filed an application on 20 o4z�>I-requesting a Certificate of Occupancy for the premises known as, SYY-e f� / Y�}�T , Rye Brook,NY, located in a PG2-F Zoning District and shown on the most current Tax Map as Section: /qj, q3Block: Lot: and having fully complied with the requirements of the Building Code and the Zoning Ordinance under Building Permit No. / , issued V �O 20 a, 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: P- d Fatn/ / Construction: for the following purposes: ge'+Ur " 1 h laurml'yVF I `Dop S) ri k- 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 shall be made,nor shall the building be moved from one location to another until a permit to accomplish such change has Peen pbtained from the Building Inspector. MAR 1 4 1021 Building Inspector,Village of Rye Brook: Date: p ECENE D ` BUILD R ENT For office use only: PERMIT#- CD0_�klo 38 KING STREMAR — 9 2022 VIL OF RYE OK ISSUED: YE BROOKy YORK 10573 DATE: `3--9—c3a VILLAGE OF RYE BROOK � � �� FEE: /D— PAm)W BUILDING DEPARTMENT APPLICATION FOR CERTIFICATE OF OCCUPANCY,CERTIFICATE OF COMPLIANCE, AND CERTIFICATION OF FINAL COSTS TO BE SUBMITTED ONLY UPON COMPLETION OF ALL WORK, AND PRIOR TO THE FINAL INSPECTION i##kit#itktrtit#t#rtrtrtrt##rtrt#####rtrti##i###ik#rtrtrttrtrt#rtrtrtrtrttrt#rtt####rtrt##rt#R####iR#iirtk#kkiR###t#tkrtirt#R#i##kkktt#krtkrtfrttt#krtrtkrtt#rt Address: l��yM N S-t NoK7:1 MOM /� Occupancy/Use: �-�i4/ Parcel ID#: � 7 3—�'—� Zone: "--1" Owner: TAIDt A GA RC t f1 Address: I W yMA IQ J;y E a Ay(CX P.E./R.A.or Contractor: Address: -� Person in responsible charge: 1,40(A Address: ] W YNA I0 _70 N Q`(C FIZZ 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: ?A O LA CA 1�( l A being duly sworn,deposes and says that he/she resides at I W YM�N St P�►O� (Print Name of Applicant) (No.and Street) t ��-- in S)t g120 Ck ,in the County of U(SSt(H E S_T(K in the State of��fV ] ,that (City/Town/Village) "�77 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:$ 12 0 900 , for the construction or alteration of: &Jurn 0 b G_e menfi -� A n i sS rcI I ly✓C1 r P wl i-� 1C�unc�r�l Gnc1 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 Swom to before me this day of M 0'f G � ,20'IQ day of , 20 4?r1QQ0j Signature of Property Owner Signature of Applicant �f101t GfRCA P ame of Property Owner Print Name of Applicant Notary Public Notary Public SHARI MELILLO Notary Public, State of New York 8/12/2021 No. 01 P.`E61600O3 Qualified in Westchester County Commission Expires January 29,20� QyE BRC�v� • �9�z BUILDING DEPARTMENT ❑BUILDING INSPECTOR �,eO-XSSISTANT 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 : � LATE: PERMIT#i-18 �� 2AC ISSUED: O ' A' CT: l l\. �3fLOCK: LOT: LOCATION: GEC , V` �.3 ISQ <f f� ' y`�CCUPANCY: ❑ VIOLATION NOTED THE WORK IS... ❑ ACCEPTED ❑ REJECTED/REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: OUGH PLUMBING ROUGH FRAMING ❑ INSULATION \ ❑ NATURAL GAS J S 1 CEO ry ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION [] FINAL ❑ OTHER _ O = e-I N N N W CFI' a) p s, N ` E � s .. � c r � © ate. W 96 ■ kn� E"r J � s � ov .,, Q ci L = 'f C vQ�' ■ ` W � 0 Q � � n4, b � � •� � r © � l� W o`� •`� a � o o � rV F- �--i le o z °) E b 00 enCtr MRr � LE � ■ r � M■■N x p M Q Q y � c® � u � V ■ �/ C!1 M � a" M ® c o = o ..� W G CA 00 i+ 16 c° s v .0 u V� Fm � cn o � E E ui LLJ } a 3 ~ p W G7 Q oppa `o -o•o C4 oC rA BUILD MENT l� W VIL OF RV OOKIR 938 KING ET RYE BR ,NY 10573 OCT - 8 2021 4 9 9-0 VILLAGE OF RYE BROOK BUILDING DEPARTMENT FOR OFFICE USE ONLY: Approval Dal" it# Application# Approval Signature: ARCHITECTURAL REVIEW BOARD: Disapproved: Date: BOT Approval Date: Case# : Chairman: PB Approval Date: Case# Secretary: ZBA Approval Date:` Case# Other: Amendment Fee: Permit Fee: - APPLICATION TO AMEND APPROVED PLANS Application dated: 1 —a I is hereby made to the Building Inspector of the Village of Rye Brook,NY,to amend the approved plans associated with an existing open permit,and/or from any prior approvals granted by the approval authority as per detailed statement described below. 1, Job Address:__1 WyMAN St' f\}c)�" Existing Permit#: 'U/Co-410 2. Parcel ID#: Z# . "jj3 —/!/# Zone:de*)— Original Approval Date:/0—&)4P— 0 3, Proposed Amendment(Describe in detail): -R e+U Y n t n C n c,_Tcn P 6T ib 'Qu n�ty A FINISHED BASEMENT NOT 4. Property Owner: C.l SEPARATE APARTMENT ON Address: C� © N (qE>q WELLING UNIT Phone# cell# q l4-33D-q $( e-mail 10. qarCIQ 1 2.0312- Applicant: rt xYl©lG� �CArcic�_, 0.h0� � ti �" Address: MF1f)I'V SC N Ojcl-k-1 hit 3KC'a/_ Ny , Phone# Cell# e-mail Architect/Engineer: 576 FOCN 14 A R C N E 5 M1 N I Address: 5 5COTT CIRCLE Y URC E 567 N� Phone# Cell# V5 — W l f e-mail 5je N e Q I A Q C101" LM 5. Occupancy;(1-Fam.,2-Fam.,Comm.,etc...)Prior to construction: Z FGM After construction: 7 FG b. Will the proposed amendment require the installation of a new,or an extension/modification to an existing automatic fire suppression system?(Fire Sprinkler,ANSL System,FM-200 System,Type I Hood,etc...)Yes:_No:✓ (if yes,you must submit a separate Automatic Fire Suppression System Permit application&2 sets of detailed engineered plans) 7. Will the proposed amendment disturb 400 sq.ft.or more of land,or create 400 sq.ft.or more of impervious coverage requiring a Storm water Management Control Permit as per§217 of Village Code?Yes:_No: Area: i 8/12/2021 8. Will the proposed agiendment require a Site Plan Review by the Village Planning Board as per§209 of Village Code? Yes: No: (if yes,you must submit a Site Plan Application,&provide detailed drawings) 9. Will the proposed amendment require a Steep Slopes Permit as per§213 of Village Code Yes: No: ✓ (if yes,you must submit a Site Plan Application,&provide a detailed topographical survey) 10. Is the lot located within 100 ft of a Wetland as per§245 of Village Code? Yes: No: ✓ (if yes,the area of wetland and the wetland buffer zone must be properly depicted on the survey&site plan) 11. Is the lot or any portion thereof located in a Flood Plane as per the FIRM Map dated 9/28/07? Yes: No: (if yes,the area and elevations of the flood plane must be properly depicted on the survey&site plan) 12. Will the proposed amendment require a Tree Removal Permit as per§235 of Village Code?Yes: No: / (ifyes,you must submit a Tree Removal Permit Application) 13. Does the proposed amendment involve a Home-Occupation as per§250-38 of Village Code? Yes: No: J If yes,indicate: TIER 1: TIER 11: TIER III: (if yes,a Home Occupation Permit Application is required) 14. Will the proposed amendment result in additional square footage to the building or subject structure,and if so,provide such additional footage here. (Please submit additional Bulk Regulation Application Pages for review) 15. What is the total added cost of the work associated with the amendment: $ 200 (The estimated cost shall include all site improvements,labor,material,scaffolding,fixed equipment,professional fees,including any material and labor which may be donated gratis.) 16. N.Y. State Construction Classification: N.Y. State Use Classification: 17. Estimated date of completion: This application must be properly completed in its entirety by a N.Y.State Registered Architect or N.Y.State Licensed Professional Engineer&signed by those professionals where Indicated. It must also 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. STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: Teel �'�a�C1A ,being duty sworn,deposes and states that he/she is the applicant above named, (print name of individual signing as the applicant) and further states that (s)he is the legal owner of the property to which this application pertains, or that (s)he is the for the legal owner and is duly authorized to make and file this application. (indicate architect,contractor,agent,attorney,etc.) That all statements contained herein are true to the best of his/her knowledge and belief,and that any work performed,or use conducted at the above captioned property will be in conformance with the details as set forth and contained in this application and in any accompanying approved plans and specifications,as well as in accordance with the New York State Uniform Fire Prevention&Building Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances and regulations.By signing this application,the property owner further declares that he/she has inspected the subject property,and that to the best of his/her knowledge there are no roof drains,sump pumps or other prohibited stormwater or groundwater connections or sources of infiltration into the sanitary sewer system on or from the subject property. Q` Sworn to before me this C�k` Sworn to before me this day of&4)-f/' , 20�0 day of , 20` t� Dot Qr, I co:i C— Signature of property Owner Signature of Applicant 14:p C'rs C-- pa 1 J� Print Name of Property Owner Print Name of Applicant G Nn ubhc f' Notary Public ALEXANDRA H.MARSHALL Notary Public,State of New York No.O1FR6363711 qualified in Westchester County Commission Expires August 28,205 8n 2i2021 i t t a ' clq _ a a C14 h ' i OC ... O s n O s � e m a O rai � e g �- r z Cc, ow Q C U N _ V1 a ^ W f u kn w IVgz co o � y _ w c 4 3 cz ri ii O V ✓ z ~ W A w U a c a '07 0%4 C*) C: 9N) 0.-0 k4CIO z x F. 96 , U ^ U O w O a � � � U G Op •• p„ W CL t t t t i r a a s a t s t t r r t t a t mm D CCENIE I 3D BUILDING DEPARTMENT SEP 2 9 2021 VILLAGE OF RYE BROOK VILLAGE OF RYE BROOK 938 KING STREET RYE BROOK,NY 10573 (914)939-0668 BUILDING DEPARTMENT www.aebrook.org ELECTRICAL PERMIT APPLICATION Westchester County Master Electricians License Required FOR OFFICE USE ONLY BP#: V EP#: Approval Date: SEP 3 X1 Permit Fee: $ Approval Signature: Other: lylod 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 an or renfove 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. /2 1.Address: n M�1J S N�f�� k.�t, �' J��� SBL:J ql, 7J —/—/4/ Zone: 2.Property Owner: PAOLO, CA?,C Address: l W�jj&� Phone#: e Iy -330- 41 9 I Cell#: 9IH email: Cn0,Cal 1 L Z(o 3.Master Electrician: To<gv SalLrN0 Address: 23 W %4-41(,NSDgUL �4w�-qor Z Lic.#: 1157 Phone#: Cell#: 314-403- 15 0 email: QW+►[.�ccl lr� LLB bane i 1.Crr.t Company Name: l,;, �r.Lt r ►- t Address: 4.Proposed Electrical Work/Fixture Count: ,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 (primindividual 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 ar(Itect,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. Swom to before me this Sworn to before me day of 20� day of ,20 Signature of Property Owner Sill4atuA of Applicant GAe c A SOS L, 44/'-0 ttName of Prope Owner Prig a of A liclic otary Public SHARI MELILLO FLORINDA BRODERICK Notary Public, State of New York NOTARY PUBLIC,STATE OF NEW YORK No. 01 ME6160063 No. 01 BR6409551 Qualified in Westchester County Qualified in Westchester Cou�J�Y Commission ExnirAs JarnTani pq p0�3 Commission Expires 09/28/20 s/1v2o21 STATEWIDE • Service With httegri�y CAD 181 Main Street,Fishkill, NY 12524 1 email:office@swisny.com SWIS JOBAPPLICATION12.72241 fax914.219.1062 • • • Office Use Elect. Permit# Date I i.a10 "�.��y 1� Bldg Permit# Utility ID# II Final Certificate# City/Village Zip Township County qk Ict Address Cross Street Section Block Lot Owner Name/Address(If different than above) Contact Number M_ 22 J— U 7 9 f E3 Basement ❑ 1st A. ❑2nd FI. ❑3rd Fl. ❑More Than 3 FI. Garage ❑Attic ❑Outside Residential 1 ❑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 IE C E �yz IS EP 29 2021 VILLAGE OF RYE BROOK BUILDING DEPARTMENT This application is valid for one(1)year from the date received by SWIS.This application is intended to cover the above listed items to be inspected,if at any time of inspection additional items have been installed,you are authorized to make the inspection and adjust the fee for the additional Items inspected.The applicant declares that there is no open applications for the above address with any other inspection company.The applicant,owner or authorized agent agrees to all the above terms and conditions as set forth for the application. Inspector Date Finalized Inspector# Company Name Date Signature Address City/State Zip Code License# Phone# J AFFIDAVIT IN SUPPORT OF FEE WAIVER RELATED TO HURRICANE IDA STATE Oil eW �\� COUNTY OF (insert name), being duly sworn, deposes and says 1. 1 am the applicant for a Building Permit/Certificate of Occupancy /Demolition Permit ectrical Permi lumbing Permit/ Fence & Wall Permit Mechanical Permit/Pod Permit (circle all that apply) f 2. I am the legal owner of property located at Rye Brook-New York(insert street address) OR I am the ntractor(Architec Co ineer/Attorney) (circle one) for the legal owner of property located at J�c N + N f ��„ , Rye Brook, New York and I am duly authorized by property owner a 6, ��+1(,' c, to make and file the accompanying application. 3. The following is a description of(1) the work to be performed under the permit for which I am applying; and (2) how the work arose as a direct result of Hurricane Ida: 4"-O'k yJo\�a r �,GM� a 4. The work described herein arose as a direct result of Hurricane Ida and does not include Work which was not caused by Hurricane Ida. Sworn to before me this o , 20_'�� Notary PuI&ARI MELILLO Notary Public, State of New York No. Ol Mtr61 C;i;;r3 Q,ia1P°ied in Westchester County Commission Exrires.I^nt.ian. FsEP 2 9 2021 jy VILLAGE OF RYE BROOK BUILDING DEPARTMENT State Wide Inspection Services 1080 Main Street Fishkill, NY 12524 a 845 202-7224 Phone 914-219-1062 Fax STATE WIDE INSPECTION SERVICES Email: office@swisny.com Website: www.swisny.com Service With /ntegr/ty BY THIS CERTIFICATE OF COMPLIANCE STATE WIDE INSPECTION SERVICES CERTIFIES THAT: Upon the application of: Upon Premises Owned by: OHM Electric LLC Paola Garcia Joseph Salerno 1 Wyman Street North 33 West Stevens Avenue Rye Brook, NY 10573 Hawthorne, NY 10532 Located at: 1 Wyman Street North, Rye Brook, NY 10573 Section: Block: Lot: Electrical Permit Number: EP21-245 141.43 14 Certificate Number: 2021-5367 Building Permit Number: BP20-20 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: 1 Wyman Street North, Rye Brook, NY 10573 The Basement,Garage,and Storage 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 20th day of October 2021. Name Quantity Rating Circuit Type Garage Switches 02 GFCI 01 Light Fixtures 06 Storage Rooms Switches 08 GFCI 04 Luminaires 08 Bathroom GFCI 01 20Amp Luminaires 02 Name Quantity Rating Circuit Type Laundry Room GFCI 02 AFCI Breaker 01 20Amp Switches 02 Luminaires 02 Dryer 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 c N � o a ° 00 w at cS u � W M C m o F. o Z w 8 = F O V w00 W Z M � � o Q ON 00 W o BUILDING DEPARTMENT OCT Z 2 2U21 VILLAGE OF RYE Pg60K 938 KING S ET RYE B NY 10573 ' VILLAGE OF RYE BROOK BUILDING DEPARTMENT wbvi .or PLUMBING PERMIT APPLICATION FOR OFFICE USE ONLY BP#: lu c.2 1a PP#: / o 7 Approval Date: OCT 2 5 1011 Permit Fee: $ La5pA Approval Signature: Other: Disapproved: (fees are non-refundable) Application dated, v2o2 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 be in conformance with all applicable Federal,State,County and Local Codes. /-- 1.Address: 1 LO Y NA N SA MT1-1 UE r6R00K SBL: � ��- ���� Zone: /Cod^^ 2.Proposed Work: i71i S 1�T,f L *t 3.Property Owner: �f�0(A G� RC Address: W Y MA tj St N �y F FEZOC7I( Phone#: V y- 330-y I Cell#: CIO y—33a -94 e email: rn A C �,hoo.c,oM 4.Master Plumber: ///YU Py'r?tLy►'-I o/-C) Address: C=-S Al"': C j C)6&-i, Lic.#: 1 Z 73 Phone#: Cell#: 2,'3-9� 4s2 33 email: c,o'»/l tv�.. Company Name: Address: 66,F-i 2 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 1st Floor 2nd Floor 3''Floor 4m Floor 5m Floor Exterior 5.*List Other Equipment/Provide Details: (Notarized Signatures Required Next 2 Pages) -1- 8/12/2021 STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: //J"� r�U�1z,-/ ,being duly sworn,deposes and states that he/she is the applicant above named, (print name of individual signing as the applicant) and further statestit(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 befoleme this Sworn to before me this day of c���,- er 20 G day of �C b ,20`a qC(-X-JC.) Ob alo C-, Signature of Property Owner Signature of Applicant 'P, O CA GA R C i'A Titiegy��'"fl�/G Print Name of Property Owner Print Name of Applicant 7 Notary Public ALEXAN RA H.MARSHALL otary-K�DWNDRA H.MARSHALL Notary Public,State of New York No.01FR6363711 Notary Public,State of New York Qualified In Westchester County No.01FR6363711 Commission Expires August 28,20 Qualified in Westchester County Commission Expires August 28,20 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 9/12/2021 • p ECENE BUILDIN(nARTMENT OCT 2 2 2021 VILLAGE OF Rytom 00K 938 KING$`SET RYIE BRq NY 10573 VILLAGE OF RYE BROOK - 41 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: 31, '�ACCA ,residing at, St N�0�7, -F\ Kyf B9COK (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; �y�4�\Q c�-_5i N OKT K ,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. �CctQ�G'c� GC t rc PC" (Signature of Property Owner(s)) rAOCA C4'1Q 6A (Print Name of Property Owner(s)) Sworn to before me this 2d Ald- day of .&4 � , 20 9)) otary Public) ALEXANDRA H.MARSHALL Notary Public,State of New York No.O1FR6363711 Qualified in Westchester Countyrl ' -3- Commission Expires August 28,20 °` 8/12/2021 Laura Petersen From: Laura Petersen Sent: Thursday, October 7, 2021 9:45 AM To: PAOLAGARCIA1203@YAHOO.COM Subject: Amendment Application - 1 Wyman Street North Attachments: Amendment to Approved Plans Application 8.2021.pdf Good morning, I have attached an application to amend the approved plans for the basement. Per Mr. Fews, after review of the revised plans, please submit the new application indicating you are returning the basement to storage space only and removing the sink and counter tops. We will then issue a revised permit for you. Please let me know if you have any questions. Thank you Laura Laura(Petersen Office Assistant Village of Rye Brook 938 King Street Rye Brook, New York 10573 Phone(914)939-0668 1 Fax(914)939-5801 1 IpetersenC ryebrook.or4 JLCr < j' �,,��7 � Q, Mike Izzo From: Paola Garcia <paolagarcial203@yahoo.com> Sent: Wednesday, July 21, 2021 3:44 PM To: Mike Izzo Subject: Basement permit- 1 Wyman St North Rye Brook Good Afternoon Thank you for calling, for your time earlier today explaining everything I wanted to know. After talking to Mr. Telmo Cabrera I have decided to place an utility sink in my laundry room. I will stop by tomorrow to make the payments for the legalization and permit. I appreciate your help. Thanks 1 Building Permit Check List&Zoning Analysis Address: V jl V-kA+j S-r SBL: l L41 . 4C1 — L — f Zone: 2 I Use: Const.Type: Other. Submittal Date: Revisions Submittal Dates: 2-D Applicant: Nature of Work I rl 1`-� ��s vw, 4- L L, !`mow 9-4 k.J r • 1 ' of c S�,t,►�-- vi ws:ZBA: 0 C T - 9 1010 PB: BOT: Other. A- k k_f0 t ob OK 0 ( ( ) FEES:Filing. 7S,, BP: E C/O: Legalization: 1 S ? Z ( ) (,)--'APP: Dated Notarized: ✓§SL: Thus I.D. Cross Connection: —i 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: Date Stamped: Sealed. Copies: Z Electronic -Other (� ( ) License: Workers Comp: Liability: Comp.Waiver. er. ( ) ( ) 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.Ca_Battery:_Other. PLUMBING:Plans: Permit: Nat.Gas: LP Gas: N/A/: Other. ( ) ( ) FIRE SUPPRESSION:Plans: Permit: N/A: Other. ( ) ( ) H.V.A.C.: Plans: Permit: N/A Other. ( ) ( ) FUEL TANK:Plans: Permit: Fuel Type: Other. 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: APPROVET REQUIRED EXISTING PROPOSED NOTES ArcLL Date• 0 C T 2 1 1010 CL= Fr a gC �Froiu: J1LLo: L1SA!• Main COV Accs.COy Ft.H Sb: Sd.H/Sb -CfA- Tot I= F�Imo: P HH' ht/Stories: notes:�J my-Ri-, np_S C•C.* 4 \ DRCuk. CERTIF461D MAIL, O y�, Clew\CC cry w BUILDING DEPARTMENT HAND DELIVERE VILLAGE OF RYE BROOK 1982 938 KING STREET RYE BROOK,NY 10573 (914)939-0668 FAX (914) 939-5801 NOTICE OF VIOLATION AND ORDER TO REMEDY SAME OWNER: VIOLATION# 1967 N NOTICE:# ` C— SECTION: t"4 I . H 3 BLOCK: LOT: THE FOLLOWING VIOLATIONS OF THE NEW YORK STATE UNIFORM FIRE PREVENTION AND BUILDING COD AND/OR,THE CODE OF THE\VILLAG OF RYE BR K WERE FOUND TO EXIST AT.... l3_�3 C A S'T'6-Q-� \V 0 X ,LOCATED IN AN a--z� ZONE, IN THE COUNTY OF WESTCHESTER,VILLAGE OF RYE BROOK,NY ON, 20 Z�. CODE SECTION TITLE/DESCRIPTION -- --------- ----- -------- ' ^9, _cam --- - -------- ----- --- - --- -- - - - - - tcg kic- _�1� _fig_-. �5-���__ ��_ ��N_� �►� �� — ------------- ----—� -- --- -- ---- — --- — - -- ��- ----�-. - -� = 2 '� �i� � � c�jr tie U� C@C� --y��� _S��x�2•_��-��--�?ccn ,l�ef� �����Q _c_C��j L�� NOTES: �a C C`` !� � N It ( r cec � J - �Ct c�C ��: � 6'Wy' V; � � +. *-" c-c, ear Yo are here y directe o contact this apartment, obtain all neces ary permits & cdm ence to correct the above captioned violation(s) immediately.Violations of the NYSUFP&BC must be remedied by, ,20�,which is thirty(30) days after the date of this notice and are returnable at the rate of$1,000,00/day for each day of continued violation, or imprisonment not exceeding one year, or both. A re-inspection of the premises is required by law to confirm compliance with this notice&all applicable codes. FAILURE TO COMPLY WITH THIS NOTICE IS A CRIME PUNISHABV' INI?SONMENT OR BOTH. c e C N C JQ- (r ❑�.BUILDING INSPECTO V C�� G� ��� ,,�.0 ASSISTANT BUILDING INSPECTOR I`�L ❑ VILLAGE ENGINEER 0 • a — wM ' o v i a js► C a rrPD - ril . .,. E o , o � f z W occr ,,.,� r•a r .�- v f - ; :, y _ f r i • W � • State rarm rire and Uasuany company A Stock Company With Home Offices in Bloomington.Illinois PO Box 88049 Atlanta GA 30356-9901 : State Farm AT2 H 28-7520 PROD F H W ax.o RENEWAL DECLARATIONS GARCIA, PAOLA 8 JULIO 1 WYMAN ST N RYE BROOK NY 10573-3425 AMOUNT DUE None Payment is due by TO BE PAID BY MORTGAGEE Policy Number: 32-BU-J247-4 Policy Period: 12 Months Effective Dates: JUN 15 2020 to JUN 15 2021 The policy period begins and ends at 12:01 am standard time at the residence premises. Homeowners Policy Your State Farm Agent EDGAR ALMANZAR Location of Residence Premises 477 CENTRAL AVE 1 WYMAN ST N WHITE PLAINS NY 10606-1530 RYE BROOK NY 10573-3425 Phone: (914)358-9712 Construction: Frame Roof Material: Composition Shingle Year Built: 1940 Roof Installation Year: 2012 Automatic Renewal If the POLICY PERIOD is shown as 12 MONTHS, this policy will be renewed automatically subject to the premiums, rules, and forms in effect for each succeeding policy period. If this policy is terminated, we will give you and the Mortgagee/Lien- holder written notice in compliance with the policy provisions or as required by law. NOTICE: You will be receiving a second envelope that will contain your new Policy Booklet and Important Notice Regarding your New Policy. Please call your agent if you have any questions. NOTICE: Information concerning changes in your policy language is included. Please call your agent with any questions. Zone: 12 Subzone: 09 Protection Class: 3 Please help us update the data used to determine your premium. Contact your agent with the year each of your home's utilities (heating/cooling, plumbing, or electrical) and roof were last updated. PREMIUM Annual Premium $1,325.00 Your premium has already been adjusted by the following: Home Alert Discount New York Tier Rating Home/Auto Discount Lead Poison Excl Total Premium $1,325.00 Prepared APR 24 2020 -�-7 Page 1 of 4 un I— StateFarm NAMED INSURFD MORTGAGEE AND ADDITIONAL INTERESTS GARCIA, PAOLA& JULIO Mortgagee JPMORGAN CHASE BANK NA Loan Number: ITS SUCCESSORS AND/OR ASSIGNS 1538357447 PO BOX 47020 ATLANTA GA 30362-7020 SECTION I - PROPERTY COVERAGES AND LIMITS Coverage Limit of Liability A Dwelling $ 540,200 Other Structures $ 54,020 Building Ordinance/Law - 10% $ 54,020 B Personal Property $ 405,150 C Loss of Use $ 162,060 Fungus (including Mold) Limited Coverage $ 20,000 Additional Coverages Credit Card, Bank Fund Transfer Card, Forgery, and Counterfeit Money $1,000 Debris Removal Additional 5% available/$1 000 tree debris Fire Department Service Charge $500 per occurrence Fuel Oil Release $10,000 Locks and Remote Devices $1,000 Trees, Shrubs, and Landscaping 5%of Coverage A amount/$750 per item SECTION 11 - LIABILITY COVERAGES AND LIMITS Coverage Limit of Liability L Personal Liability (Each Occurrence) $ 1,000,000 Darnage to the Property of Others $ 1,000 M Medical Payments to Others (Each Person) $ 5,000 INFLATION Inflation Coverage Index: 320.2 DEDUCTIBLES Section I Deductible Deductible Amount Other Losses 1/2% $ 2,701 Hurricane 5.00% $ 27,010 LOSS SETTLEMENT PROVISIONS Al Replacement Cost - Similar Construction B1 Limited Replacement Cost - Coverage B 111 1- 32-BU-J247-4 �• StateFarm FORMS, OPTIONS, AND ENDORSEMENTS HW-2132 Homeowners Policy Option ID `Increase Dwlg up to $108,040 Option JF Jewelry and Furs $1,500 Each Article/$2,500 Aggregate HO-2687 "Work Comp Select Residence Emp HO-2679 `Away From Prem Theft Exclusion HO-2444 "Back-Up Of Sewer Or Drain - 5%of Coverage A/$ 27,010 HO-2684 'Hurricane Deductible "New Form Attached ADDITIONAL MESSAGES State Farm@ works hard to offer you the best combination of price, service, and protection. The amount you pay for homeowners insurance is determined by many factors such as the coverages you have,the type of construction, the likelihood of future claims, and information from consumers reports. Other limits and exclusions may apply - refer to your policy Your policy consists of these Declarations,the Homeowners Policy shown above, and any other forms and endorsements that apply, including those shown above as well as those issued subsequent to the issuance of this policy. This policy is issued by the State Farm Fire and Casualty Company. Participating Policy You are entitled to participate in a distribution of the earnings of the company as determined by our Board of Directors in accordance with the Company's Articles of Incorporation, as amended. In Witness Whereof,the State Farm Fire and Casualty Company has caused this policy to be signed by its President and Secretary at Bloomington, Illinois. Secretary President Prepared APR 24 2020 Page 3 of 4 un I— DECLARATIONS Coverage afforded by this policy is provided by: State Farm Fire and Casualty Company We will provide the insurance described in this policy PO BOX 88049Atlanta GA 30356-9901 in return for the premium and compliance with all applicable provisions of this policy. A Stock Company with Home Offices in Bloomington, Illinois. 32-BU-J247-4 Policy Number Named Insured and Mailing Address Garcia, Paola &Julio 1 Wyman St N Rye Brook, NY 10573-3425 The Policy Period begins and ends at 12:01 a.m. Automatic Renewal - If the Policy Period is shown as Standard Time at the residence premises. 12 months, this policy will be renewed automatically 06/15/2021 Effective Date subject to the premiums, rules and forms in effect each 12 months - Policy Period succeeding policy period. If this policy is terminated, we 06/15/2022 Expiration of Policy Period will give you and the Mortgagee/Lien holder written Limit of Liability-Section 1 notice in compliance with the policy provisions or as $594,300 Dwelling required by law. $445,725 Personal Property(Minimum 75% of Deductibles - Section 1 1/2% $2,971 Dwelling) ALL LOSSES In case of loss under this policy, the Limit of Liability -Section 2 deductible will be applied per occurrence and will be $1,000,000 Personal Liability deducted from the amount of the loss. $5,000 Medical Payments to Others Earthquake: o Hurricane 5% $29,715 Policy Type Homeowners Policy Premium $1444 Al - Replacement Cost-Similar Construction Increased Dwelling Up to$118,860 -Option ID Location of Premises 1 Wyman St N Rye Brook, NY 10573-3425 Forms, Options, & Endorsements HW-2132 Homeowners Policy Hurricane Deductible Back-Up of Sewer Or Drain Amendatory Endorsement Mortgagee &Addl. Interests Agent Name&Address Mortgagee Edgar Almanzar JPMORGAN CHASE BANK NA ISAOA/ATIMA 477 Central Ave PO Box 4465 White Plains, NY 10606-1530 Springfield, OH 45501-4465 (914) 358-9712 Loan Number: 1538357447 Prepared: 10-15-2021 Agent's Code:2267 559-916.5 APPLICANT COPY 1000007 2020 127534 219 0423-2021 Affidavit of Exemption to Show Specific Proof of Workers' Compensation Insurance Coverage for a 1, 2, 3 or 4 Family, Owner-occupied Residence "This_/orm cannot be used to waive the workers'compensation rights or obligations of any party." 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 applying for, and I�am not required to show specific proof of workers' compensation insurance coverage for such residence because (please check the 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)performing all the work for which the building permit was issued or helping me perform such work. L�J I have a homeowners 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(aggregate hours for all paid individuals on the jobsite)for work indicated on the building permit,or if appropriate,file a CE- 200 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 hours for all paid individuals on the jobsite)for work indicated on the building permit. &Itui "/ k 0— (Signature of Homeowner) (Date Signed) (f Aw G t2 i Home Telephone Number (Homeowner's Name Printed) Sworn to before me this �___ day of Property Address that requires the building permit: S4 K7rAN -i n V (County Clerk g JYrkgy�P1�blic) 1�5�3 Notary Pub�lic,,IStta�tLe.ILoff Now York No.01 ME6160063 Qualffled in Westchester County Commission Expires Januar,-29.20 co�3 Once notarized,this BP-I form serves as an exemption I'or both workers'compensation and disability benefits insurance coverage. BP-1 (12/08) NY-WCB Affidavit of Exemption to Show Specific Proof of Workers' Compensation Insurance Coverage for a 1, 2, 3 or 4 Family, Owner-occupied Residence "This form cannot be used to waive the workers'compensedon rights or obUgadons of any party.•" 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 applying for, and I am not required to show specific proof of workers' compensation insurance coverage for such residence because (please check the 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)performing all the work for which the building permit was issued or helping me perform such work. ❑ I have a homeowners 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(aggregate hours for all paid individuals on the jobsite)for work indicated on the building permit,or if appropriate,file a CE- 200 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 hours for all paid individuals on the jobsite)for work indicated on the building permit. �acIou Go VC, o (Signature of Homeowner) (Date Signed) �P(O C A A�PC( A Home Telephone Number (Homeowner's Name Printed) Sworn to before me this day of Property Address that requires the building permit: Ud XNflN -TH • ( o�unty Clerk o c) �y ( .cC4 N 3 Notary Public, State of New York j No.01 ME6160063 Oualified in Westchester County Commission Exoires January 29.20D3 Once notarized,this BP-1 form serves as an exemption for both workers'compensation and disability beneSts insurance coverage. BPA (12/08) NY-WCB = -, = •• rA t O — O 'v M I 04 0. O w W ~ a E cc a c O Gn c e O M - Z ►� _ L U H F I .' (ou ,Lr h� C) O ,.. W Z I c j = - O0 > Z tection f^ a z y W w co)s O W W GCL Ca o m aces» cq � w w F, ca ,[(ems)► - O =: `"•o a " f to O — Y cc M =_ co U � H M • eo v � r- G U =�.►,. yy �1 * LA U ray.-•edE.? A ,4co CERTIFICATE OF LIABILITY INSURANCE DA07/09/2DJY021 TE �� 7/09/21 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 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 CONTACT Genesis Manscal NAME: North Main Street Insurance Agency PHONEftils, �(914 1-6334 IrI FAX -- -L No: 375 North Main St .r1LAIL nmsinsuranoeIagmai-com Port Chester, NY 10573 MigtNtEWJ AFFORDING COVERAGE rM�e NSURERA: Preferred Contractors Insurance Company INSURED Cabrera Home Improvements LLC INWRERc: 226 Madison Ave. INSURERG: Port Chester. NY 10573 INSURERE: 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. POLICY OF POLICY am at TYPE OF INSURANCE AM— POLICY NLMIe■t LIMITS e6MAiML.LIAINUTY EACH OCCURRENCE i 1,000,000 DAMAGE TO RENTEU— COMMERCIAL GENERAL LIABILITY PREMISES IZA courrence) $ 1,0w,ow CLAIMS-MADE X OCCUR MED EXP( or* II 51000 A PC370W7 11/10/2020 11/10/2021 PERSONAL aADVpuuRy S 1,000,000 -- GENERAL AGGREGATE a 2,000.000 GENT-AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG S 2,000,000 POLICY F`RD-ECT Loc = - AUTOMO@"UA UW COMBINED (fa am rr ANY AUTO eODLY KJURY(Per person) _ ALLOVMIEO SCHEDULED BODILY MAW(Par { AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY = AUTOS Per t UMBRELLALMA OCCUR EACH OCCURRENCE i EXCESSLM CLAIMS-MADE AGGREGATE { DED I I RETENTION S >< * RKERS COMPENSATION 1W STATU- OTN- AND EMPLOYERSLIAe1LITY YIN —1 ER - -. ANY PROPRIETORIPARTNERIEXECUTIVE E-L EACH ACCIDENT = OFFICERIMEMBER EXCLUDED N/A (Mandatory In NH) E.L.DISEASE-EA S r yyesss describe under - -- - DESCRIPTION OF OPERATIONS bebw E.L.DISEASE-POLICY LIMIT I S i i DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,AddOr l Remarks Schedule,If more space Is requimA) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Village of Rye Brook THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 938 King St ACCORDANCE WITH THE POLICY PROVISIONS. Rye Brook. NY 10573 AUTHORIZED REPRESENTATNE Nwt cd ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD NYSIF New York State Insurance Fund WESTCHESTER ONE,44 SOUTH BROADWAY, 10TH FLOOR.WHITE PLAINS,NY 1 0601-441 1 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE 0 -T7 ^^^^^^ 200558213 CABRERA HOME IMPROVEMENT, INC 226 MADISON AVENUE Q PORT CHESTER NY 10573 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER CABRERA HOME IMPROVEMENT, INC. VILLAGE OF RYE BROOK 226 MADISON AVENUE 938 KING STREET PORT CHESTER NY 10573 RYE BROOK NY 10573 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE W2072 015-7 1 692736 03/28/2021 TO 03/28/2022 7/9/2021 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2072 015-7, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTPS://WWW.NYSIF.COM/CERT/CERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THIS POLICY DOES NOT COVER CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED BY THE OFFICERS OF THE INSURED CORPORATION. PRESIDENT TELMO CABRERA CABRERA HOME IMPROVEMENT. INC. ONE PERSON CORPORATION THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. NEW YORK STATE INSURANCE FUND DIRECTOR.INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 38571837 U-26 3 oR workers' CERTIFICATE OF INSURANCE COVERAGE -.- sTATF Compensation Board DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by Disability and Paid Family leave Benefits Carrier or licensed Insurance Agent of that Carrier 1a. Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured CABRERA HOME IMRPOVEMENT INC 914-424-2107 226 MADISON AVENUE PORT CHESTER,NY 10573 1c. Federal Employer Identification Number of Insured Work Location of Insured On! or Social Security Number (only required d coverage is specifically limited to certain locations in New York State,i e, Wrap-Up Policy) 200558213 2.Name and Address of Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) ShelterPoint Life Insurance Company Village of Rye Brook 938 King St. 3b Policy Number of Entity Listed in Box"la" Rye Brook, NY 10573 DBL476028 3c Policy effective period 10/24/2020 to 10/23/2022 4. Policy provides the following benefits © A. Both disability and paid family leave benefits B.Disability benefits only ❑ C.Paid family leave benefits only 5. Policy covers © A.All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law B Only the following class or classes of employer's empioyees. Under penalty of penury.I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above 44/1440 Date Signed 7/9/2021 By 4 (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 516-829-8100 Name and Title Richard White, Chief Executive Officer IMPORTANT If Boxes 4A and 5A are checked,and this form is signed by the insurance carrier's authorized representative or NYS Licensed Insurance Agent of that carrier, this certificate is COMPLETE. Mail it directly to the certificate holder If Box 46,4C or 5B is checked,this certificate is NOT COMPLETE for purposes of Section 220, Subd 8 of the NYS Disability and Paid Family Leave Benefits Law. It must be mailed for completion to the Workers'Compensation Board, Plans Acceptance Unit, PO Box 5200, Binghamton, NY 13902-5200. PART 2.To be completed by the NYS Workers'Compensation Board (Only if Box 4C or 513 of Part 1 has been checked) State of New York Workers' Compensation Board According to information maintained by the NYS Workers'Compensation Board,the above-named employer has complied with the NYS Disability and Paid Family Leave Benefits Law with respect to all of his/her employees. Date Signed By (Signature of Authorized NYS Workers'Compensation Board Employee) Telephone Number Name and Title Please Note:Only insurance carriers licensed to write NYS disability and paid family leave benefits insurance policies and NYS licensed insurance agents of those insurance carriers are authorized to issue Form DB-120 1. Insurance brokers are NOT authorized to issue this form. t i. 30 �. -- 0 ) W � 1LAI 9 LJ f—.p a � 6 - >t ter• _ PERMIT 0 � -� ��► � sew i'�I_�'� < <�t jiWING M3 CTOR,Village O/RP SMOk WIF 13 FILE COPY General Notes 1141 J� 1)All work to be done according to 2020 Residential Code of REVS New York State and local codes JML2)All plumbing work to be done by a licensed plumber PLAt OCT-7 2021 3)All electric work to be done by a licensed electrician DATE D: 4)Dryer vent to vent to exterior K BUILDING DEPARTMENT zj� a-eV1551P ?� SEAL Project E ?JFI� poR M3Z5•< L�2fjL Drawing Number pc fief>\, 1 WYM J ST N(:,e7 4 w ti Fs SMM Architect PLLC Drawing Date q/24).0Zn 16gsfl, yob 5 Scott Circle TJ Scale Y/Irl i0 of Purchase,New York 10577 � Drawn By