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BP20-216
PERMIT Jf/JVCoK� s g dg SECTION 1 *4 TYPE OF WORK JOB LOCATI N OWNER Q/ ` CON" �3 0 ot/c— � DATE O it FEE�DATE INSPECTION RECORD DATE FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING Me RGH PLUMBING GAS L7 SPRINKLER 12,0000 ELECTRIC LOW -VOLT O ALARM AS BUILT FINAL ` INSP cQi(4 4* (0c� ,1}c Y939-jy13Co OTHER APPROVALS ARB BOT PB ZBA OTHER P� \C) -/ c //�� — yl J-? �aG�ei �;��'v�dr�a►i.n` y � 5/-1ea�'�g — GG VILLAGE Fes' 1 YF, BROOK WESTCHESCOurA Y, Nrw YORK 77 , >, ' � - � No: 23-182 Certif irate of ®ccupaucp Ehis is to certify that /^7 ���QyQ &;zl� of, V , having duly filed an application on / 20 J3 requesting a Certificate of Occupancy for the premises known as, , Rye Brook,NY, located in a, /5 Zoning District and shown on the most current Tax Map as Section: )c - 7 Block: —L—Lot: / 41• / , and having fully complied with the requirements of the Building Code and the Zoning Ordinance under Building Permit No. issued �� 20 �, such authority and permission is hereby granted IL to the property owner to lawfully occupy or use said premises or building or part thereof listed under the following New York State Classifications,Use: R„3 {0" / Construction: , for the following purposes: YPin0 de/ 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 no shall a building be moved from one location to another until a permit to accomplish such change h &eobta' o th ilding Inspector. 7 Building Inspector,Village of Rye Brook: Date: NOV 2 1 2023 Qy� DRCi c..tc 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 November 21,2023 Robert&Tamora Miller III LLC 48 Hawthorne Avenue Rye Brook,New York 10573 Re: 48 Hawthorne Avenue, Rye Brook,New York 10573 Parcel ID#: 135.75-1-74.1 This document certifies that the work done under Mechanical Permit #23-141 issued on 10/5/2023 for the removal of a mini-split HVAC unit and condenser has been satisfactorily completed. Sincerely, Steven E. Fews Building& Fire Inspector /to D E C E� V E BUILD R ENT For office use only: PERMIT# VIL OF RYE K ISSUED: —ol AUG 12 2021 8 KING STREE YE BROOK, YORK 10573 DATE: — a—a I (914)9 939-5801 FEE: /I O— PAID,K VILLAGE OF RYE BROOK o .or BUILDING_ DEPARTMENT PPLICATION OR 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 *******x*xxxxxxxxsxxxxxxx******ss****s*sxx**s*s*sx*s****x***x*x*xxxsssxssssxxxxxxx*xxx*x**x*xx******sxx*x**********sxxxxxxssx ' f Address: ) ( ! a6v �w a hy &0 NV 7�> Occupancy/Use: I —`4A4f Parcel ID#: 75 7q, / Zone; Sfy Owner: Rb be�+cl 71. MY& milIj V]:]E u..c Address: LOLL u L&tN u� P.E./R.A. or Contractor: d2mmw Address: Person in responsible charge: Address: '[�6' /,I L04 CI (fit AV�-t C) Y pp 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 ' ,,O�F/�NEyW/�Y+ iOIR'K,,COUNTY OF WESTCHESTER as: f�)2fV 7- 1�1 U IZA being duly sworn,deposes and says that he/she resides at (Print Name of licant) (Nd and Street) in /70 in the County of xhl y!'&J—k� in the State of—�/—that (City,Town/ illage) 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,profession f s,and incl ding the monetary value of any materials and labor which may have been donated gratis was:$ 1Jrj04 ,/ �{ for the construction or alteration of: LAIkk1l"-/ l t A W1 I 6L A UA f OeLIA r- A eXIOA Deponent further states that he/she has examined the approved plans of the structure/work herein eferred 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 §250-1 O.A.of the Code of the Village of Rye Brook. Sworn to before me this /V41-' Sworn to before me this day of , 20 day of , 20 Signature of Pro Owner / Signature of Applicant J 1ki Print N Property Owner Print Name of Applicant Nota e — , -- Notary Public PAUL FRANCIS t Notary Public,State of New York r No.01FR5051872 ;. II Qualified in Putnam County Commissiun Expitss f.oventber 13,20a� i QyE BRC�k. 1982 BUILDING DEPARTMENT UILDING INSPECTOR ❑ASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK ❑CODE ENFORCEMENT OFFICER 938 King Street • Rye Brook,NY 10573 (914) 939-0668 FAx (914) 939-5801 www Uebrook.org - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS: w Vr ` " DATE: 12C12(;2? PERMIT# V v ISSUED:�0CT: BLOCK: LOT: LOCATION: 1 �v F-� v OCCUPANCY: y ❑ Violation Noted THE WORMS... PASSED ❑ FAILED REINSPECTION ❑ SITE INSPECTION �, ("„ �j � REQUIRED ❑ FOOTING `+o ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ Natural Gas ❑ L.P. Gas ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ OSS CONNECTION FINAL 1 -7 _ I<_/ ❑ OTHER V� �( 2 BUILDI INSPECTOR BUILDING DEPARTMENT �] NG ❑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: d 4 PERMIT ���� ISSUED: ( ECT: BLOCK: LOT: LOCATION: .4-0 �\� �y �" �"y � �'�� 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 ❑ FUEL TANK ) ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL AC ❑ OTHER (-} n 1 6 \ � - �_� C I e�•� N oG �? C4 M M a 3! M > °� C ww A. ►.y Q r � O� � W � m ON O LL1 r U � Q W6 co oo v� � � � 4 w- F Lu rx O mm 3 I W Z o Z oc c U f z Ono z Wo � a � O a 7_ ca V z z cg s Col., 401 . - EC ENE NC BUILDING DEPARTMENT NOV 13 2020 VILLAGE OF RYE BROOK 938 KING STREET RYE B ,NY 1057 VILLAGE OF RYE BROOK (914)93q'. R , , 939-5801 BUILDING DEPARTMENT Nw or , ELECTRICAL PERMIT APPLICATION Westchester County Master Electricians License Required hOR OFFICE l_SE, ONL1 BP#: �� ��� EP#: �0?4P7 Approval Date: Permit Fee: $ I�O Approval Signature: Other: Disapproved: (fees are non-refundable) ************************************************************************************************** Application dated, I �1-rQis 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 he in conformance with all applicable Federal,State,County and Local Codes. 1.Address: ` �T n� 1�i+V '�(�1��Q y SBL: 3S: S -� -7 L{ 1 Zone: P^/5� 2.Property Owner: tl`o b e.r �-x Tit vr►o r� M 1 I(e.1,,u 4dress: Phone#: J4 -45D- It+0 6 Cell#: email: A 14 ot C,%-,4�V4 s e C4h oj.C 6 W` 3.Master Electrician: A-(\ lQ'}1 t () Address: lS ( h � " (,j Lic.#: Phone q I��I(} -II V email:_j►1 4- (1nCe ' mi,n J-n c" Company Name: (eGfY1C_-/ Address: 4.Proposed Electrical Work/Fixture Count: rvv STATE=NEWORK,COUNTY OF WESTCHESTER ) as: 1N tam?being duly swom,deposes and states that he/she is the applicant above named,and does further ( tint nanie of individual signin . 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 architict, ontract� or,age6t,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,ordin d regulations. Ad !fore me this Swo o be f me is 0 d of ,� )iat e of Property Own r Signa of plicant 1 Name of Property wner Prmt N&Se of Applicant StfVN /• MON Notar GASMON W YORK Not ,ice W �K me. 0 1002 0 „ ouamled �r ow" U C Nt C My Coi+►mfubn ooleb�r 11,40i� N'Comm(plon Eu*'p, fOW if,!0� 3/21/19 Westchester Rockland Electrical Inspection Services, Inc. Phone: 914-347-3595 DO NOT WRITE HERE-FOR OFFICE USE ONLY 43 North Lawn Avenue y Fax: 914-347-3596 Elmsford, NY 10523 BUILDING PERMIT NO. TEMP# DATE 1e v CITY OR VILLAGE ZIP CODE TOWNSHIP COUNTY - STREET AND NO.OR RO Ll POLE NUMBER —1 BETWEEN WHAT TWO CROSS STREETS IS PREMISES LOCATED? SECTION BLOCK LOT OCCUPANT'S NAME BUILDING OCCUPANCY OWNER'S NAME AND ADDRESS HOME TELEPHONE NUMBER 11 L� (�. CURRENT SUPPLIED BY FROM THEIR OFFICE WORK TELEPHONE NUMBER LIST BELOW ALL EQUIPMENT WHICH YOU INSTALLED NUMBER OF OUTLETS NO.OF FIXTURES 8 MOTORS HEATERS OFFICE USE LOCATION LAMP RECEPTACLES ONLY SIDEWALL SWITCH INCADE FLUORE NO. H.P.EACH NO. WATTS EACH INSPECTION OUTSIDE BASEMENT luj L�= ini i 1"FL. n 11111 2'FL. !-209201 3'FL. VILLA BUILD NG DELARTMF.Nf 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[I ADDITIONAL❑ EXPOSED❑ CONCEALED❑ MUST ENTER APPLICANTS IDENTIFICATION NUMBER SERVICE ENTERS BUILDING OVERHEAD❑ UNDERGROUND L] AVOID DELAYS BY GIVING FULL AND ACCURATE INFORMATION.ALL SPACE MUST BE FILLED IN OR APPLICATION MAY BE RETURNED. NAME OF COMPANY , DATE OF APPLICATION SIGNATURE OF APPLICANT X STREET ADDRESS TELEPHONE NO. CRY OR POST OFFICE ZIP CODE LICENSE NO.WHEN APPLICABLE EL G ` V� IF WESTCHESTER ROCKLAND ELECTRICAL INSPECTION MWEISSERVICES,INC. BY THIS CERTIFICATE OF COMPLIANCE THE Westchester Rockland Electrical Inspection Services 43 North Lawn Ave, Elmsford, NY 10523 914-347-3595 (Office) 1 914-347-3596 (Fax) CERTIFIES THAT Upon the application of: Upon premises owned by: Zaccagnino Electric Robert &Tamor Miller LLC 81 Maple Avenue Rye NY 10580 Located at: 48 Hawthorne Ave, Rye Brook, NY 10573 Certificate Number: 754876 Section: 135.75 Block: 74 Lot: 1 BDC: Permit Number: EP:20-227 BP:20-216 A visual inspection of the electrical system at this premise described as a Residential occupancy, wherein the premises electrical system consisting of electrical devices and wiring, described below, located in/on the premises at: 48 Hawthorne Ave, Rye Brook, NY 10573 ❑Basement ❑X 1st Floor ❑2nd Floor 03rd Floor ❑Garage ❑Attic ❑Outside Other: Inspection was conducted in accordance with the NYS and NFPA 70-2017 International Electrical Code and detail of the installation, as set forth below, was found to be in compliance therewith on 11/18/2020 Name Quantity Rating Circuit Type Range Hood 1 Dishwasher 1 Heater 1 Kick Space This Certificate has been approved by Westchester Rockland Electrical Inspection Services. This certificate may not be altered in any way. This certificate is valid for work performed before date of inspection only. a s zrA w0-4 OO \ C F 3 W Ln C0-1 W w C7 w c� � � Z W co 00 V z 5 O _ v 0-4 0 u � H � a ►-� W z S z° cn WF--+ F z vWi i z �-+ ON V w z ON M y z p4 O 0 ° oG F+N g z o C W Ln 00 w 0z A 0y et W N o < .. 9 a W a W a � �I m a w z � E IBR j L BUIL u � E \✓MENT ,' Ir` VrL E OF RYE OK - 2 2023 938 KIN T RYA B ,NY 10573 VILLAGE OF RYE BROOK o BUILDING DEPARTMENT ELECTRICAL PERMIT APPLICATION Westchester County Master Electricians License Required FOR OFFICE USE ONLY .+P' �/ �'-,� EP#: - OCT 0 5 Approval Date: Permit Fee: $ Approval Signature: Other: Application dated, 10/2/23 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. 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: 48 Hawthorne Ave SBL: 135.75-1-74.1 Zone: �e-/5-4 2.Property Owner: Robert Miller Address: Phone#: 914-450-1406 Cell#: email: 3.Master Electrician: Angelo Zaccagnino Address: 81 Maple Ave,Rye NY 10580 Lic.#: 755 Phone#: 914-921-3244 Cell#: email: nffice@Zaccagnino.net Company Name: Zaccagnino Electric Address: 4.Proposed Electrical Work/Fixture Count: Removal of wiring associated with the S n o HVAC unit in the attic Angelo Zaccagnino MO.& 12111/1m Company: 5.3'�Party Electrical Inspection Agency: SWIS Zaccagnino no Electric +r******:************r** *****�r:***********t,r,r***,t****�►**,t t 81 Maple Avenue Rye,NY 10580 STATE OF NEW YORK,COUNTY OF WESTCHESTER ) at Angelo Zaccagnino ,being duly swom,deposes and states License No. 755 (print name of individual signing as the applicant) Expires on:12/31/2023 Peter 0orduCCi state that(s)he is the legal owner of the property to which this application pertains,or that(s)he is the hlectncran 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. Swo ore is 1�2 Sworn to before me this 2nd y of 20-;L,3— day of October 120 23 t. Signature o Property Owner Si JA)Cjff�I XLC44� ki Print e of Property Owner nt Name oSfEifEAc$n NON A iON — f NEW PORK NEW fORK Notary PublirNo. 0 1 0238 t 013 Qyplitied es fC !stet County Cuo"ited in st ester COuntlt� 17 My Commission Euptres ctobet 14. My COn1M3610 spires OC1Obef 14.26_Ef_ 6/232022 STATEWIDE • Service With baegri�v 1:1 Main Street,Fishkill, NY 12524 1 email:office@swisny.com SWIS JOB APPLICATION :• 1 914.219.1062 • • Elect.Permit# �� � � � Date �- Bldg Permit# �n _ � � / Utility ID# Final Certificate/#�1/J City/Village Zip Township County Address Cross Street Section Block Owner Name/Address(if different than above) �1 ' r ( Contact Number r I v ❑Basement ❑ 1st Fl. ❑2nd Fl. ❑3rd Fl. ❑More Than 3 Fl. ❑Garage ❑Attic ❑Outside ❑Residential ❑Commercial Receptacles Special Recept GFCI AFCI Switches Dimmers Smoke Alarms Carbon Monox Hood Trash Compact Amt Amps Range(s) Cooktop(s) Oven(s) Dishwashers Refrigerator Disposal Microwave Warm Draw Incandescent Fluorescent SERVICE Amperage Voltage 1 P I 3P #Meters #Disconnect ❑underground ❑ New ❑Reconnect ❑Overhead ❑Change ❑Visual Re-Inspection Safety Re-Inspection ❑ Re-Inspection Additional Information i�PvMoOal oC W; ci55�� , Wt +N\- .: Avb L 0y) I D MC OCT - 2 2023 VILLAGE OF RYE BROOK BUILDING DEPARTMENT This application is valid for one(1)year from the date received try 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 Inspe to # Company Name Date Signa ure Address City/State Zip r.re License# Phone# State Wide Inspection Services CAS 1080 Main Street NOV — � 2023 ` Fishkill, NY 12524 T �0 Z 845 202-7224 Phone VILLAGE OF RYA BROOK 914-219-1062 Fax STATE WIDE INSPECTION SERVICES BUILDING DEPARTMENT Email: office@swisny.com 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: Zaccagnino Electric Robert&Tamora Miller III LLC Angelo P. Zaccagnino 48 Hawthorne Avenue 81 Maple Avenue Rye Brook, NY 10573 Rye, NY 10580 Located at: 48 Hawthorne Avenue, Rye Brook, NY 10573 Section: Block: Lot: Electrical Permit Number: EP 23-217 135.75 1 74.1 Certificate Number: 2023-7982 Building Permit Number: BP 20-216 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: 48 Hawthorne Avenue, Rye Brook, NY 10573 The Attic and Exterior 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 1st day of November 2023. Name Quantity Rating Circuit Type Removal of All Associated Electrical Wiring Associated with HVAC System Only Officer: Frank J. Farina This certificate may not be altered in any way and is validated only by the presence of a seal at the location indicated.This certificate is valid for work performed on the date of inspection only. r � s co r A Ono ~ M O A v; O, ~ Y oG U < p U M0-.0M Z „� ., w 41 v; r 00 F� Q6 a w -- WW F o a Q 3 w Lg 00 ,qT w z Q o0 r i $EEIT BUILMENT f rj 2 8 LQ Q 1 VIL K938 KIN NY 1057 VILLAGE 01= RYf= BROOK 91419939-5801BUILC!NG DEPARTMENT w .or PLUMBING PERMIT APPLICATION FOR OFFICE USE ONLY BP#: c�O-- PP#: Approval Date: I'O Permit Fee: $ �cyJ�• 0o Approval Signature: Other: Disapproved: `-- (fees are non-refundable) Application dated, /0 &40 a 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�thhat said plumbing work will be in conformance with all applicable Federal,State,County and Codes. /) 1.Address: O SBL: l 3L 7S /—/— 7• Zone: — 6A 2.Proposed Work: 3.Property Owner: _ / Address: fl Phone#: — Cell#: email:AlvcialL7o 4.Master Plumber: / Address: �J Lic.#: 7100 Phone#: �— �/y�� Cell#:�f/���t email: cs, Company Name: Address: �4;ccc at cba`_ asS'/l�y l/ G'm . 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 4's Floor 5 Floor Exterior 5.*List Other Equipment/Provide Details: (Notarized Signatures Required Next 2 Pages) BUILD MENT VIL E OF R% OK 938 KING ET RYE BR NY 10573 OCT 2 8 2020 91 1 --- 1 (914)9 914)�9;39-5801 VILLAGE OF RYE BROOK J, ' jILDING DERAPTIVIENT W 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, Kb , residing at, rQ �dj (h I ) I ey, -blZ &Y 1096 i Print name) (.-'WL1ress'A here VOLI li�'C) r —0 being duly sworn, deposes and states that (s)he is the applicant above named, and further states that (s)he is the legal owner of the property to which this Affidavit of Compliance pertains at; R_V e soe� P� ) L�-)]� I Rye Brook,NY. I (Joh Aki'l , 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. (SienatUre ot'Property Owner(s l) i Print Name ot'Property Ownerw) Sworn to before me this gejf- day of e0C�&bef- .9202-0 14— PAUL FRANCIS Notary Public, State of New York No. 01FR5051672 Oualified in Putnam �cunty Commissiur, 13, 20,2L -3- 3/21/19 r STAT OF NEW YO COUNTY OF WESTCHESTER ) as: 1 , s being duly sworn,deposes and states that he/she is the applicant above named, (print name of indivi 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 �,.,t�y A In 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 920 day of ,20?,0 Signature of Property Owner Signature of AFplicant Print Name of Property Owner a of Applicant Notary Public tary Pub 'c �#��«�«�LraN�yy�i y This application must be properly completed in its entirety and must includVtotina re(s) of a ,pE HEW Y the legal owner(s) of the subject property, and the applicant of record in thl spa �'. ications carp: not properly completed in its entirety and/or not properly signed shall be dj%A vo will be returned to the applicant. '•y, MSON -2- 3/21/19 erg W � O p i a n Ln No W ►r O � H � R. Y M i � � w to I OHre) a � j o � u O z o o ff o � f -Log A L r � ►-� W M [� '� 3 � a''py 0 00 A �V U rn u vPLO z Pq 7 a Fij C � W aW' o; z C � < r; o o 'C a•y -v >` � w tj PLO W0-4 64 W Wok V� A w w V LO � - A Cjo� � w z O tt , V z u ONO ►-O u v 6 W Z x a o z ? � � o v; / w y w L) b _ ~ 0oc -- Oci y 8 C db u L) �. V � 0 w o z c } A o z E.y A WCt. 96 z 4 OP � oaG QI a s a° a z �� U r BUILDING.DEPARTMENT VILL O�E OF RYE BROOK D [ECEMED 938 KING STREET RYE BR4oK,NY 10573 (914)939-0668 O C T - 5 2023 VILLAGE OF RYE BROOK APPLICATION FOR PERMIT TO INSTALL AND/0R9E9MftE9KPARTMENT HEATING, VENTILATION AND/OR AIR CONDITIONING QEQUIPME�NfT/ FOR OFFICE USE ONLY: PERMIT#: / �_3 —/ Approval Date: V rJ Permit Fee: $ mod Approval Signature: Other: Disapproved: (fees are non-refundable) REQUIREMENTS FOR RELEASE OF PERNUT&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#C105.2 or Form#U26.3/or NY State Workers Compensation Waiver) 4. Payment of Fees/Unit: RESIDENTIAL=$100.00/unit•COMMERCIAL=$350.00/unit. 5. Complete specifications for each unit being installed. 6. Inspection by the Building Department for removal and/or installation. (48 hour notice required 7. Electrical work requires a separate Electrical Permit&Electrical Inspection. 8. Plumbing/Gas work requires a separate Plumbing Permit&Plumbing Inspection. Application dated, t.�,3 is hereby made to the Building Inspector of the Village of Rye Brook for a permit for the installation and or removal of the RVAC 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. / -7 --7�/ /� 1. Address: 4� � /��{ SBLJ 3St /S'L-L/7, Zone: nE)" ISA 2. Property Owner: {�l; ✓ //.(l fl Z&k 1))dJrY�U-C-Address: L IL 1 `f Q Phone#: ��yV f 1 `- 7 6I 6' Cell#: 7�/y"y5L'"/yl)to email: (Z (' 4� G "1 .'R 3. Contractor: Address: Phone#: Cell#: email:; 1( 4. Scope of Work:New Installation( )•Replacement -TCemoval •Other( ): 5. List Equipment: M,,t- \. S/L�L� SV� �i�l 1- �Q S e V S C S-,&A c C,(� 6. Location of Equipment: 1 d CIL,4,- 4 l 7. Method of Installation/Removal(list all equipment needed to perform job): i 3/3/2023 l STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: �i IW� I ►-jaf(�' ,being duly swom,deposes and states that he/she is the applicant above named, (print narad of individual signing as the applicant) and further states that(s)he is the Heating,Ventilation and/or Air Conditioning Contractor for the legal owner and is duly authorized to make and file this application. 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 Q 8 Sworn to before nr this day of h 20Z day of e 20 f Signature o Prope er afore f , can LYDIA MERCURIOlid e of Property Owner) NOTARY PUBLIC, STATE OF NEW YO t of Applic \ NO. 01 ME4769385 Qualified in Putnam Coun tary Pu lic Commission Expires July 31 _' o Public PAUL FRANCIS Notary Public, State of New York ; i No. 01 FR5051872 i� j Qualified in Putnam '�ounty 1 Commissior, Expires November 13,20&%�-'.; 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. 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 3/3/2023 Building Permit Check List&Zoning Analysis Address: H Q�) t 7kQ C-- . SBL• 741. 1 • Zone: Sl- I -5 A Use: Z l o Const.Type: � Other. l-Z A-rTO �+ Submittal Date: Revisions Submittal Dates: Applicant: L«!Z— Nature of Work: t KA-r•F-fL A a P_ r--' -4-\3 A--r 4- Reviews.ZBA T 27 ING PB: BOT: Other. [ c:�(OK �A S,W4 I O• ' ( ( ) FEES:Filing. 7.S�r BP: ZZS- � � C/O: Legalization: ! t �y,0O• — lob( ) (.�-APP: Dated: ✓Notarized: ---SBL Truss I.D. Cross Connection: --� H.O.A.: ( ) ( ) Scenic Roads: Steep Slopes: Wetlands: Storm Water Review: Street Opening. ( ) ( ) ENVIRO:Long. Shore Fees: N/A: ( ) ( ) SITE PLAN:Topo: Site Protection S/W Mgmt.: Tree Plan: Other. ( ) ( ) SURVEY:Dated: Current: Archival• Sealed: Unacceptable: ( ) ( ) PLANS:Daze Stamped: Sealed-. Copies: Electronic: Other. (�( ) License: Workers Comp: Liability Comp.Waiver. Other. ( ) ( ) CODE 753#: Dated: N/A: (� ( ) HIGH-VOLTAGE ELECTRICAL:Plans: Permit N/A: Other. ( ) ( ) LOW-VOLTAGE ELECTRICAL:Plans: Permit N/A: Other. ( ) ( ) FIRE ALARM/SMOKE DETECTORS:Plans: Permit: H W.I.C.:_Battery._Other (% ( ) PLUMBING:Plans: Permit: Nat.Gas: LP Gas: N/A/: Other. ( ) ( ) FIRE SUPPRESSION:Plans: Permit N/A: Other. ( ) ( ) H.V.A.C.: Plans: Permit: N/A Other. ( ) ( ) FUEL TANK Plans: Permit: Fuel Type: Other. ( ) ( ) 20I7 NY State ECCC: N/A: Other. ( ) ( ) Final Survey Final Topo: RA/PE Sign-off Letter. As-Built Plans: Other. ( ) ( ) BP DENIAL LETTER: C/O DENIAL LETTER: Other. ( ) ( ) Other ( )ARB mtg.date: approval: notes: ( )ZBA mtg.date: approval: notes: ( )PB mtg.date: approval: notes: REQUIRED EXISTING PROPOSED NOTES APPROVED DA". OCT 2 7 20MQ Cir e: Froze Front: Front: Sides: Rcar. Main Cov Accs.Cor. Ft.H Sb: S .H Sb: QFA: Tot.bnv: Ft.I : Par . Hight/Stories: notes: CC o jo a •� �„ ( oai � F � o w z 3 ' Z o ea .�.. n O 0 A O •� 0) o m a � � I IA v1 '� cc A c_ W w W �-V m mCPS o Z H r 45Ea w wo ; A Q � 00 c c z Q S r = W a O � o F M.y O Ono j u W A I � Em 1�1 `I � fI ' • w oW 3 0 A O Z YI `` I - -:... . zm- toic �., f ,a � - N Laura Petersen From: Alycia L. Forbes <alycia.forbes@yahoo.com> O Sent: Friday, October 23, 2020 1:20 PM c D W, IE To: Laura Petersen Subject: 48 Hawthorne ave kitchen picture I OCT 2 3 2020 VILLAGE OF RYE BROOK BUILDING DEPARTMENT i Sent from Yahoo Mail on Android i • Masterpiecea Premium Summary CHUBS' D IZ 3 1111 LOCCT 2 3 2020 LO VILLAGE OF RYE BROOK ROBERT AND TAMORA MILLER III LLC Page 1 BUILDING DEPARTMENT 29 LOCUST AVE Effective Date 9/2/20 RYE. NY 10580 Policy no. 15087866-01 Policy period 9/2/20 to 9/2/21 Producer name RSC INSURANCE BROKERAGE INC We are pleased to enclose your Chubb Masterpiece Policy, customized to provide the coverage you requested. This chart shows at a glance what coverages you have and the related premiums. Property covered Coverage Premium Homes and Contents HOUSE AT HOME, CONTENTS $ 3,517.00 48 HAWTHORNE RONE AVENUE RYE BROOK. NY Total Premium $ 3,517.00 Your policy includes a Coverage Summary and policy provisions that explain your coverage in more detail. Chubb Masterpiece provides many different credits for home, valuable articles, automobile and excess liability coverages. We recommend that you contact your agent or broker for an annual review to ensure that your coverages, policy limits and available credits are accurate and meet your personal insurance needs. You will receive a separate Personal Insurance Statement that will outline the schedule of premium amounts and the due dates. If an endorsement during the policy period changes the amount of premium due, you will receive a revised Personal Insurance Statement. If you choose one of our convenient installment plans, your payments will be slightly higher than the premium shown above because of the small service charge. We appreciate your business. Since 1882, personal service and comprehensive coverages have been the hallmarks of the Chubb Group of Insurance Companies. Thank you for insuring through Chubb. C Chubb 2016. All rights reserved Form no 00700000 • masterpiece. CHUBB* CHUBB GROUP U.S. PRIVACY NOTICE FACTS WHAT DOES THE CHUBB GROUP DO WITH YOUR PERSONAL INFORMATION? Insurance companies choose how they share your personal information. Federal and state law gives consumers the right to limit some but not all sharing. Federal and state law also requires us to tell you how Why? we collect, share, and protect your personal information. Please read this notice carefully to understand what we do. The types of personal information we collect and share depend on the product or service you have with us. This information can include: What? aSocial Security number and payment history • insurance claim history and medical information • account transactions and credit scores When you are no longer our customer, we continue to share information about you as described in this notice. All insurance companies need to share customers' personal information to run their everyday business. In How? the section below, we list the reasons insurance companies can share their customers' personal information; the reasons the Chubb Group chooses to share; and whether you can limit this sharing. Reasons we can share your personal information Does Chubb share? Can you limit this sharing? For our everyday business purposes - YES NO such as to process your transactions, maintain your account(s), respond to court orders and legal investigations, or report to credit bureaus For our marketing purposes -to offer our YES NO products and services to you For joint marketing with other financial YES NO companies For our affiliates' everyday business YES NO purposes - information about your transactions and experiences For our affiliates' everyday business NO We don't share purposes - information about your creditworthiness For our affiliates to market to you NO We don't share For nonaffiliates to market to you NO We don't share Questions? Call 1-800-258-2930 or go to https://www2.Chubb.com/us-en/privacy.aspx ® Chubb 2016 All nghts reserved Form no 0799999 (Rev 10-16) Reference Copy Page 2 Who is providing The Chubb Group, A list of these companies is located at the end of this document. this notice? p What we do How does Chubb To protect your personal information from unauthorized access and use, we use security measures Group protect my that comply with federal law. These measures include computer safeguards and secured files and personal buildings. information? We restrict access to personal information to our employees, affiliates' employees, or others who need to know that information to service the account or to conduct our normal business operations. How does Chubb We collect your personal information, for example, when you Group collect my personal apply for insurance or pay insurance premiums information? 0 file an insurance claim or provide account information • give us your contact information We also collect your personal information from others, such as credit bureaus, affiliates, or other companies. Why can't I limit all Federal law gives you the right to limit only sharing? • sharing for affiliates' everyday business purposes - information about your creditworthiness • affiliates from using your information to market to you • sharing for nonaffiliates to market to you State laws and individual companies may give you additional rights to limit sharing. See below for more on your rights under state law. Definitions Affiliates Companies related by common ownership or control. They can be financial and nonfinancial companies. • Our affiliates include those with a Chubb name and other companies, such as Westchester Fire Insurance Company and Great Northern Insurance Company. Nonaffiliates Companies not related by common ownership or control. They can be financial and nonfinancial companies. • Chubb does not share nonaffiliates so they can market to you Joint Marketing A formal agreement between nonaffiliated financial companies that together market financial products or services to you. • Our joint marketing partners include categories of companies such as banks. O Chubb 2018 All rights reserved. Form no.07999% (Rev. 10.16) Reference Copy CHUBB- Page 3 Other important information For Insurance Customers in AZ, CA, CT, GA, IL, MA, ME, MN, MT, NV, NC, NJ, OH, OR, and VA only: Under state law, under certain circumstances, you have the right to see the personal information about you that we have on file. To see your information, write Chubb Group Attention: Privacy Inquiries, 202 Hall's Mill Road, P.O. Box 1600, Whitehouse Station, NJ 08889-1600. Chubb may charge a reasonable fee to cover the costs of providing this information. If you think any of the information is not accurate, you may write us. We will let you know what actions we take. If you do not agree with our actions, you may send us a statement. If you want a full description of privacy rights that we will protect in accordance with the law in your home state, please contact us and we will provide it. We may disclose information to certain third parties, such as law enforcement officers, without your permission. For Nevada residents only: We may contact our existing customers by telephone to offer additional insurance products that we believe may be of interest to you. Under state law, you have the right to opt out of these calls by adding your name to our internal do-not-call list. To opt out of these calls, or for more information about your opt out rights, please contact our customer service department. You can reach us by calling 1-800-258-2930, emailing us at privacyinquiries@Chubb.com, or writing to Chubb Group, Attention: Privacy Inquiries, 202 Hall's Mill Road, P.O. Box 1600, Whitehouse Station, NJ 08889-1600. You are being provided this notice under Nevada state law. In addition to contacting Chubb. Nevada residents can contact the Nevada Attorney General for more information about your opt out rights by calling 775-684-1100, emailing bcpinfo@ag.state.nv.us, or by writing to: Office of the Attorney General, Nevada Department of Justice, Bureau of Consumer Protection: 100 North Carson Street, Carson City, NV 89701. For Vermont residents only: Under state law, we will not share information about your creditworthiness within our corporate family except with your authorization or consent, but we may share information about our transactions or experiences with you within our corporate family without your consent. Chubb Group Companies Providing This Notice This notice is being provided by the following Chubb Group companies to their customers located in the United States: ACE American Insurance Company, ACE Capital Title Reinsurance Company, ACE Fire Underwriters Insurance Company, ACE Insurance Company of the Midwest, ACE Life Insurance Company, ACE Property and Casualty Insurance Company, Agri General Insurance Company, Atlantic Employers Insurance Company, Bankers Standard Fire and Marine Company, Bankers Standard Insurance Company, Century Indemnity Company, Chubb Custom Insurance Company, Chubb Indemnity Insurance Company, Chubb Insurance Company of New Jersey, Chubb Lloyds Insurance Company of Texas, Chubb National Insurance Company, Executive Risk Indemnity Inc., Executive Risk Specialty Insurance Company, Federal Insurance Company, Great Northern Insurance Company, Illinois Union Insurance Company, Indemnity Insurance Company of North America, Insurance Company of North America, Pacific Employers Insurance Company, Pacific Indemnity Company, Penn Millers Insurance Company, Texas Pacific Indemnity Company, Vigilant Insurance Company, Westchester Fire Insurance Company and Westchester Surplus Lines Insurance Company. C Chubb 2016 All rights reserved. Form no 0799999 (Rev 10-16) Reference Copy Masterpiecen Premium Discount Summary CHUBB- Name and address of Insured: Page: 1 Policy no: 15087866-01 ROBERT AND TAMORA MILLER III LLC Policy period: 9/2/20 to 9/2/21 29 LOCUST AVE RYE, NY 10580 We know that you've worked hard for what you own and want to protect it. We also know that saving money is important to you. You may be able to take advantage of a variety of discounts offered by Chubb such as: •Discounts for anti-theft features (e.g., burglar alarms in homes, anti-theft devices in automobiles, home safe for valuable articles) •Discounts for safety measures (e.g., in homes: gated communities, security features, fire alarms, fire-resistant construction, and windstorm-resistant construction. In automobiles: anti-lock brakes, air bags, completing defensive driving courses, etc.) *Portfolio discounts for insuring a combination of your home, automobile and valuable articles with Chubb You have the power to reduce your premiums. Not all discounts are available in all states and automobile coverage is not available in all states. Please contact your agent to discuss discounts that you may be eligible for, or visit http://chubb.com/ and select Individuals & Families, then select the Help tab and scroll for the Discounts section. 0 Chubb 2016 All nghts r"@N.d Form no 09300000 Reference Copy • ma-sterpiJorgou Coverage Summary CHUBB` Name and address of Insured Page 1 Effective date 9/2/20 ROBERT AND TAMORA MILLER III LLC Policy no. 15087866-01 29 LOCUST AVE Issued by Chubb National Insurance Company RYE, NY 10580 a stock insurance company incorporated in Indiana Policy period 9/2/20 to 9/2/21 If you have any questions, please contact RSC INSURANCE BROKERAGE INC 900 STEWART AVE STE 505 GARDEN CITY, NY 11530 516.683.0500 This Coverage Summary is part of your policy. PLEASE READ YOUR POLICY CAREFULLY, INCLUDING THIS COVERAGE SUMMARY, FOR A COMPLETE DESCRIPTION OF YOUR COVERAGES. Homes and Contents Your policy provides coverage against physical loss if your home or its contents are damaged, destroyed, or lost. The kinds of losses that are covered, and any special limits that apply, are explained in detail in the policy. Address Dwelling Contents HOUSE AT $975,000 $48,800 48 HAWTHORNE RONE AVENUE DELUXE COVERAGE DELUXE COVERAGE RYE BROOK, NY EXTENDED REPLACEMENT COST REPLACEMENT COST The base deductible for each occurrence is $5,000. We will waive the base deductible for covered losses of more than $50,000 except for covered losses subject to any special deductibles. Special deductibles include the vacant house deductible, water backup deductible, wind or hail deductible, and earthquake deductible. Additional coverages or conditions Mold remediation expense limit In addition to the standard $20,000 mold remediation expense limit, you have 25% of the amount of coverage for your house as shown in the Coverage Summary at the time of a covered loss for mold remediation expenses for your residence at 48 HAWTHORNE RONE AVENUE, RYE BROOK, NY. This limit does not increase the amount of coverage for your house, other permanent structures or contents (if coverage is provided under this policy) and will not be affected by any increase in the amount of house coverage caused by the application of extended replacement cost payment basis. Important notice regarding mold remediation expense limit This limit for mold remediation expenses cannot be increased except upon a renewal of this policy, subject to underwriting acceptance. You may decrease the limit shown above at any time. ® Chubb 2016 All rights reserved. Form no 00802000 Reference Copy Coverage Summary Page 2 Effective date 9/2/20 Policy no. 15087866-01 Name ROBERT AND TAMORA MILLER III LLC Homes and Contents (Continued) Other permanent structures You have up to $48,800 of Other permanent structures coverage for your residence at 48 HAWTHORNE RONE AVENUE, RYE BROOK, NY. The first paragraph of Extended replacement cost payment basis in Deluxe House Coverage is deleted and replaced with the following for this location: Extended replacement cost. If the payment basis is extended replacement cost, and the loss is to your house, we will pay the reconstruction cost even if the amount is greater than the amount of coverage for your house as shown in the Coverage Summary. If the reconstruction cost of other permanent structures exceeds the amount of coverage for other permanent structures as shown in the Coverage Summary, we will pay up to 25% more than this amount of coverage, if necessary, for the reconstruction cost. Off premises theft Under your New York Deluxe Contents Coverage , Exclusions, the following is added: Off premises theft. We do not cover any loss caused by theft to contents off the residence premises located at 48 HAWTHORNE RONE AVENUE, RYE BROOK, NY. Equipment Breakdown Coverage Enhanced Equipment Breakdown Coverage Your policy provides you with Enhanced Equipment Breakdown Coverage for equipment breakdown to your residential equipment at 48 HAWTHORNE RONE AVENUE, RYE BROOK, NY. Your amount of coverage is $100,000 for this location. The deductible for each occurrence is $2,500. The kinds of losses that are covered, and any limits that apply, are explained in detail in the policy. As the duly authorized representative of the company my signature validates this policy. Paul N. Morrissette Authorized representative ® Chubb 2016 All rights reserved. Form m C0802000 Reference Copy • Meister iece® Additional Interests Summary CHUBB' Name and address of Insured Page 1 Effective date 9/2/20 ROBERT AND TAMORA MILLER III LLC Policy no. 15087866-01 29 LOCUST AVE Issued by Chubb National Insurance Company RYE, NY 10580 a stock insurance company incorporated in Indiana Policy period 9/2/20 to 9/2/21 If you have any questions, please contact RSC INSURANCE BROKERAGE INC 900 STEWART AVE STE 505 GARDEN CITY, NY 11530 516,683.0500 This summary lists the Additional Interests you have requested to be shown on your policy. We notify each Additional Interest separately. Regardless of the number of Additional Interests shown on your policy, the amount of coverage for any one occurrence does not increase. Additional Interests This section shows the Additional Interest(s) for your home(s) shown below. Address Additional Interest HOUSE AT ROBERT & TAMORA MILLER 48 HAWTHORNE RONE 29 LOCUST AVE AVENUE RYE, NC 10580 RYE BROOK, NY ® Chubb.2016 Al rights reserved Form no C16010000 Reference Copy • masterpwrp Table of Contents CHUBB' Name and address of insured Effective date 9/2/20 Policy no. 15087866-01 ROBERT AND TAMORA MILLER III LLC Issued by Chubb National Insurance Company 29 LOCUST AVE a stock insurance company RYE, NY 10580 incorporated in Indiana Policy period 9/2/20 to 9/2/21 If you have any questions, please contact RSC INSURANCE BROKERAGE INC 900 STEWART AVE STE 505 GARDEN CITY, NY 11530 516.683.0500 This table of contents lists your policy provisions. Please attach this table of contents to your policy so you have a current list of your coverages at all times. Contents Chapter Edition Date State Page Introduction A-1 Deluxe House Coverage 11/17 N Y B-1 Deluxe Contents Coverage 11/17 N Y C-1 Enhanced Equipment Breakdown Coverage 11/17 N Y S1-1 Policy Terms 11/17 N Y Y-1 Policy Information Notice 11/17 N Y ® Chubb 2016 All rights reserved Form No 00903000 Page 1 Reference Copy • m�terpiece,, Introduction CHUBS' This is your Chubb Masterpiece Policy. Together with your Coverage Summary, it explains your coverages and other conditions of your insurance in detail. This policy is a contract between you and us. READ YOUR POLICY CAREFULLY and keep it in a safe place. Agreement We agree to provide the insurance described in this policy in return for your premium and compliance with the policy conditions. Definitions In this policy, we use words in their plain English meaning. Words with special meanings are defined in the part of the policy where they are used. The few defined terms used throughout the policy are defined here: You means the person named in the Coverage Summary, and a spouse who lives with that person. For your New York coverages, the following definition of Spouse is added: Spouse means a partner in marriage or a domestic partner registered under state law and who lives with you. We and us mean the insurance company named in the Coverage Summary. Family member means your relative who lives with you, or any other person under 25 in your care or your relative's care who lives with you, or a student under 25 in your care temporarily away at school who is a resident of your household. Policy means your entire Masterpiece Policy, including the Coverage Summary and any Mortgagee's Coverage Summary. Coverage Summary means the most recent Coverage Summary we issued to you, including any subsequent Coverage Updates. Occurrence means a loss or accident to which this insurance applies occurring within the policy period. Continuous or repeated exposure to substantially the same general conditions unless excluded is considered to be one occurrence. Business means any employment, trade, occupation, profession, or farm operation including the raising or care of animals. Introduction Page A-1 ®Chubb 2016 All nghts reserved Form no 0200000 .Reference Copy masterpiecea Certificate of Insurance CHUBB' Name and address of additional interest Effective date 9/2/20 Policy no. 15087866-01 ROBERT & TAMORA MILLER Policy period 9/2/20 to 9/2/21 29 LOCUST AVE Issued by Chubb National Insurance Company RYE, NC 10580 a stock insurance company incorporated in Indiana Name and address of insured ROBERT AND TAMORA MILLER III LLC 29 LOCUST AVE RYE, NY 10580 This certificate verifies that the company shown above has issued to the named insured the insurance coverages and limits shown below. These coverages are subject to the provisions of the policy and are in force as of the effective date shown above. This certificate does not in any way change or extend the policy coverages. Property covered Amount of coverage Type of coverage Deductible Home $975.000 DELUXE COVERAGE $5,000 Other Permanent Structures $48,800 DELUXE COVERAGE $5,000 Payment of losses We will pay losses to the Additional Interest and the Named Insured in proportion to their interests. Cancellation or Nonrenewal If we intend to cancel or nonrenew the policy, we will notify the additional interest at least 10 days before the cancellation or nonrenewal takes effect. Producer's name and address RSC INSURANCE BROKERAGE INC 900 STEWART AVE STE 505 Paul N. Morrissette GARDEN CITY, NY 11530 Authorized representative O Chubb.2016 All righls reserved, Form no Q1800000 Reference Copy 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'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 der-oc ie( residence a � —ram (including condominiums) listed on the building permit that I am applying for, an f(i'e Wry 'to show specific proof of workers' compensation insurance coverage for such residence , OCTse eck the appropriate box): 2 3 262;li I am performing all the work for which the building permit was issued. VILLAGE OF RYE BUILDING DEPAF; ' ❑ 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 take total of 40 hours or more per week(aggregate hours for all paid individuals on the jobsite)for work in i a e on the building permit. Z 1 0-*23-714U Signature of Homeowner) (Date Signed) 4) onpe-cs Home Telephone Number ( omeowner's Name Printed) Sworn to before me this _ day of Property Address that requires the building permit: c",,r _____ �l Al k � ; _ oAf CA I' (County C or N t y Public) T,l�f{ ,(�t�{;�b lL, �y `QS�3 CHRISTOPHER J.BRADBURY Notary Public,State of New York No.01 BR6159985 Qualified in Westchester County Commission Expires Januar 29 20 '73 Once notarized,this BM form serves as an exemption for both workers'compensation and disability benefits insurance coverage. BP-1 (12/08) NY-WCB Aco CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) `� 10/2/2023 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 Michaels M.Wilbert NAME: i►/c Miller Miller Insurance Agency Inc PHONE -914-741-6400 F No:914-741-6407 720 Commerce Street E-MAIL Thornwood NY 10594 ADDRESS: michaelew@miller-ins.com INSURERS AFFORDING COVERAGE NAIL t INSURER A:Hartford Fire Insurance Co 19682 INSURED JDAHE-2 INSURER B J. Daher Air Conditioning And Heating Corp INSURERC: PO Box 19 INSURERD: Gedney Station INSURERE: White Plains. NY 10605 INSURER F: COVERAGES CERTIFICATE NUMBER: 138702549 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. �TR TYPE OF INSURANCE I DL S VO POLICY NUMBER M/DD/YLICY YYY MPOLICY EXP LIMITS A GENERAL LIABILITY 16SBAPC2788 3/31/2023 3/31/2024 EACH OCCURRENCE $1,000,000 DAMAGE X _COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $300,000 CLAIMS-MADE a OCCUR MED EXP(Any one person) $10,000 PERSONAL 3 ADV INJURY $1,000,000 GENERAL AGGREGATE $2.000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY X PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ 4 EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE❑ E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S If yes.describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) 'Policies shown are subject to terms,conditions,exclusions,sublimits and deductibles not listed on this certificate. We recommend that requests for policy copies be directed to the Named Insured shown above.' 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 938 King Street Rye Brook NY 10573 AUTHORIZED RE ESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD i� NYSIF New York State Insurance Fund PO Box 66699.Albany. NY 12206 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ^^A^^ 132620071 *. .W, .� . KEEVILY,SPERO-WHITELAW INC. �_ T•'Y 500 MAMARONECK AVENUE HARRISON NY 10528 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER J DAHER AIR CONDITIONING & VILLAGE OF RYE BROOK HEATING CORP 938 KING STREET PO BOX 19 GEDNEY STATION RYE BROOK NY 10573 WHITE PLAINS NY 10605 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE G 1004 885-8 776056 05/01/2023 TO 05/01/2024 10/3/2023 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 1004 885-8, 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. IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY, INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTPS:I/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 NOUHA DAHER 1-1 OF J DAHER AIR CONDITIONING& HEATING CORP 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 SUR NCE FUND T �V DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 16421226