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HomeMy WebLinkAboutBP20-270PERMIT # 6d..Z� Q 70 SECTION _ 30.v 7 7 TYPE OF WORK JOB LOCATION OWN CO BEST. COST V CO # 1C' TCO # _ EXP: _ LOT 0 l 41CA77 44a/I 3 /) FEE_! - pI� 4 /a6 /� D FEE 6 ,YQ� 0b DATE FEE ' DATE _ INSPECTION RECORD DATE I NSP FOOTING FOUNDATION FRAMING RGH FRAMING -/ q INSULATION 416,eorge, PLUMBING RGH PLUMBING GAS 90VICI(cot ` SPRINKLER L� / ELECTRIC LOWE VOLT Pt LAP. IVI AE BUILTL'.k FINAL OTHER APPROVALS ARB BOT PB ZBR OTHER VILLAGE OF RYE BRooK WESTCHESTER Coo-N^TY, NEw YORK NO: 21-178 Certif Irate of (Occupaucp Ehis is to certify that .n 4z !1h ea le, L Chh-00/-7 of, NJ having duly fled an application on 20LED I requesting a Certificate of Occupancy for the premises known as, `TU � ! ) 'Q�L 1'o I f Q U' ,Rye Brook,NY, located in a IQ'95 Zoning District and shown on the most current Tax Map as Section: 13b, / Block: / Lot: 5 and having fully complied with the requirements of the Building Code and the Zoning Ordinance under Building Permit No. issued /,,>I q 20 J20, 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 New York State Use Classification of: for the following purposes: l y 4cr rd r k4oher� reh o Ya-Hoi-3 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 trade,and no enlargement, whether by extending on any side or by increasing in heig t sha L be made,nor shall the building be moved from one location to another until a permit to accomplish such change has b ob i i _. g Inspector. Building Inspector,Village of Rye Brook: ate: NOV 1 0 2021 BUILDR ENT For office use only: vIL o YE I{ PERMIT# —Q'20 BD f TZ ISSUED: Ja- �� ao l OCT 1 3 2021 38 KING S rREE Yt BeoO>Rc, YoRt� 14573 DATE:10-f 3-Q (914)9 939-5801 FEE:&f/O— PAIR VILLAGE OF RYE BROOK o u 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 fiiit!lkiii RRiiiRitlktiitlili##R##Riiit!#ktitiii#tt###Rkiki RRt#tt##it##tt t i i####if itttttttffM ff ffffiif it t t#fat#t t tffitfRi#ff Address: LtO V l l w,,J e_ 1 >° a y /057 Occupancy/Use: I—r4M Parcel ID#: / 3(Di 7i 7 —/—S- Zone: -tt-).- Owner: Address: Q - ' P.E./R.A. or Contractor: / -)X-0'I, Address: Person in responsible charge: Cr &,)q J -L Address: i-4t7 Application is hereby made and submitted to the Building Inspector of the Village of Rye Brook for the issuance of Certificate of Occupancy/Certificate of Compliance for the structure/construction/alterat ion herein mentioned in accordance with law: STATE OF NEW YORK,COUNTY OF WESTCHESTER as: ' ' Eu��•;7 being duly swots,deposes and says that he/she resides at q0 A J'�A (Pant/Name(;fApplicant),ram (No.and Street) in �L fA- Tno Q ,in the County of�4Q � in the State of N� _,that ityfrown/Village) he/she has supervised the work at the location indicated above,and that the actual total cost of the work,including all site improvements,labor, materials,scaffolding,fixed equipment,professional fees,and including the monetary value of any materials and labor which may have been donated gratis was:$ / for the construction or alteration of lr 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 §250-1 O.A.of the Code of the Village of Rye Brook. Sworn to before me this 3+#) Sworn to before me this day of 202 1 day of , 20 Signature operty Owne Signature of Applicant r b t Z Pri ame of Property Omber Print Name of Applicant Public h aNDRA Fi, ARSRALL Notary Public Notary Public,State of New York No.01FR6363711 Qualified In Westchester County 3t�le Commisslon Expires August 28,20+W- QyE BRC�,�, 04 2m BUILDING DEPARTMENT ❑BUILDING INSPECTOR ASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK 114❑CODE ENFORCEMENT OFFICER 938 KING STREET • RYE BROOK,NY 10573 (914)939-0668 FAx (914) 939-5801 www.ryebrook.org - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - -- - -- - - -- - _ - - - - i ADDRESS : DATE: PERMIT# ISSUED: ECT: ILOCK: LOT: LOCATION: <<3�C "^ LEI'``tA 9 ` "V UCCUPAN Y: ` ❑ VIOLATION NOTED THE WORK IS... ACCEPTED D REJECTED/ REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTINGIc ❑ FOOTING DRAINAGE ❑ FOUNDATION UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ROUGH FRAMING ❑ INSULATION ❑ NATURAL GAS ❑ L.P. GAS �42 4 ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING eF OSS CONNECTION AL HER iE DRCu , 0 yc�+ W -�0c '9�2 BUILDING DEPARTMENT ❑BUILDING INSPECTOR XASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK f[I CODE ENFORCEMENT OFFICER 938 KING STREET - RYE BROOK,NY 10573 (914) 939-0668 FAX (914) 939-5801 www.ryehrook.org - - - - -- - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - -- - --- ADDRESS : L4 -Le TDATE: PERMIT# � ISSUED: SECT: LOCK: LOT: \` LOCATION; �4 ` r 6-) OCCUPANCY: Z ❑ VIOLATION NOTED THE WORK IS... ❑ ACCEPTED REJECTED/REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING/_DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION 1 � c ❑ NATURAL GAS 1 "V�J ❑ L.P.GAS ❑ FUEL TANK { \ FIRE SPRINKLER 0 1 "�t�"� cn�J�'� c-0 ❑ FINAL PLUMBING ,CROSS CONNECTION �] FINAL ❑ OTHER �a s f ■ 0 ! IN ! QI 0�0 0`0 •� °y O lot ik �0 a � x I-. 3 �. w 12 '4: z gz � � Q 4 w � � 0 w Lz, L— U , co ;D w � IX .. C6 a u o � , ww © �/ (> Cc Now `r Q Q v N - OIN �.. z f4 o a z 74 U w z a rj z A `� �� •. �y, Lz. GL . BUILD E�'.A,.R MENT [ECIEME VILLAGE OF RYE BOOK 938 KING STREET RYE BROOK,NY 1057 AUG - 9 2021 (914)939-0668 FAX(914)939-5801 wNv�\.rvehroolc.orl? VILLAGE OF RYE BROOK BUILDING DEPARTMENT ELECTRICAL PERMIT APPLICAT Westchester County Master Electricians License Required (` FOR OFFICE USE ONLY BP#: — �D —�7 EP#: — � ] — / `► 7 Approval Date: AUG Permit Fee: S Approval Signature: Other: Disapproved: (firs are non-refundable) Application dated, is hereby made to the Building Inspector of the Village of Rye Brook NY,for the issuance of a Permit to install and/or remo a 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 inn conformance with all applicable Federal, State,County and Local Codes. 1.Address: 4 f-f!' IAiV bA � IL Q/ SBL- ,�3Q- -7- "j—5 Zone: f- � 2.Property Owner_ G' /V 1 % Address: Phone#: Cell#. 3 — - 71 ail: 14/4 QN't rZ SF— (2 `C,,"�Tr(naC j. Le 3.Master Electrician: ©SE V i O i Address: '�d 3 of E L.S01Y /4✓E —,I ✓l Lic.#: 13148 Phone#: Cell#: mail: i C G A✓1 b I A o Company Name: GAy-Il i Q F,!F(Tf I Address: 105 "ELL AJ A — I RISbAy f J y 4.Proposed Electrical Work/Fixture Count: ELe c nzt` C A L !!!!!!!latR!!!!!!!!!!!!!!lRRRlR#RR#*RlRRRRRRRRRR!!!!!!!!lRRRRRRRRR RRRRRRRRRRRR*RiF>�*R RRRRatRRRR R*RRR*RR*!!*R STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: S-t; 280L /"g- ,being duly sworn,deposes and states that he/she is the applicant above named,and does further (Print name of individual signing as the applicant) state that(s)he is the legal owner of the property to which this application pertains,or that(s)he is the for the legal owner and is duly authorized to make and file this application. (indicate architect,contractor,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 worts 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 fore me this 17 d 20 day of 20?_L_ Si a-tuti Prope er Signature of Ap t ant r Print Name of Property Owner Print Name of Applicant Notary Public Not BUOZZO - NWAW PUBGC,STATE OF NEW YORK ReglstratEon No.01 SU8070919 Oualifled In Westchester County My Commission Expires March 11,2022 3/2]/19 STATEWIDE INSPECTION Service With bilegrit-Y 1080 Main Street, . . • SWIS JOBAPPLICATIONi 0. Office Use Elect.Permit# �( CJ Bldg Permit# J 0 _ 70 Utility ID# Final Certificate# f _ _ City/Village `4— Zip /1 t2S ? -7 1 Township County 1, -- , i NC- 4 Address J f / � L 11, Cross Street Section Bock 1 Lot Owner Name/Address of different than above) _� L i\l) A L)�J t T— 7 Contact Number (� 3 f 7°-7g -7 77/ l ❑Basement 0 1st FI. ❑Znd FI. ❑3rd FI. ❑More Than 3 FI. ❑Garage ❑Attic ❑Outside R]Residential ❑Commercial Receptacles Special Recept GFCI AFCI Switches Dimmers Smoke Alarms Carbon Monox Hood _ Trash Compact Amt Amps Range(s) Cooktop(s) Oven(s) Dishwashers Refrigerator Disposal Microwave Warm Draw Incandescent Fluorescent SERVICE Amperage Voltage 1 P 3P #Meters #Disconnect ❑Underground ❑New ❑Reconnect ❑Overhead ❑Change ❑Visual Re-Inspection ❑ Safety Re-Inspection ❑ Re-Inspection Additional Information ELL• C-T) LAB Te_' i4e—,A LIAT I;W p CIEWED AUG - 9 2021 VILLAGE OF RYE BROOK BUILDING DEPART1JiENT This application.Is valid for one 11)year from the date received by SIMS.This application is intended to cover the above listed items to be inspected,if at any time of inspection additioral items have been installed,you are authorized to make the inspection and adjust the feefw 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 authwrized agent agrees to all the above terms and conditions as set forth for the appikation. Inspector Date Finalized Inspector# Company Name �d r� �� / Date ;� Signature fi Address103 ALLLO City/State I Zip e �7 License# wig—_ . G r C k Phone# f�-'19�4 State Wide Inspection Services 1080 Main Street Cjk--]> Fishkill, NY 12524 ls $45 202-7224 Phone 914-219-1062 Fax STATE WODE INSPECTION SERVICES Email: office(d)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: Gavidia Electric, LLC Brad Kaunitz&Nicole Lichtman Jose C Gavidia Asencios 40 Hillandale Road 103 Nelson Avenue Rye Brook,NY 10573 Harrison, New York 10528 Located at:40 Hillandale Road, Rye Brook, NY 10573 Section: Block: Lot: Electrical Permit Number: EP 21-197 130.77 Certificate Number: 2021-4160 Building Permit Number: BP 20-270 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:40 Hillandale Road, Rye Brook,NY 10573 The First Floor Kitchen was 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 24th day of August 2021. Name Quantity Rating Circuit Type AFCI Circuits 08 Recessed Luminaires 05 Pendant Lights 02 Switches 04 Receptacles 17 Hood 01 Refrigerator 01 Garbage Disposal 01 Dishwasher 01 Microwave 01 rpm 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. 5 6♦ 6! aj 6! *d J� N N to OW C7 [` N o_G N frj � C4 O/ co 70 00 �j p C7 oz° 0*14 w a a a C�l o 0.0 Y � 06o p a f of 4r, ' BuILO� G DEPARTMENT OCT 15 2021 VIUAGE OF RYE"ROOK 938 KiNO,:�RET RYE B ,NY 10573 VILLAGE OF RYE BROOK . % BUILDING DEPARTMENT www6 9ok.org PLUMBING PERMIT APPLICATION FOR OFFICE USE ONLY BP#: c�)o'a-7o PP#: 0 I r /10 7 Approval Date: OCT I g Permit Fee: $ /Q15 - 106 Approval Signature: Other: Disapproved: (fees are non-refundable) Application dated, -Z I is hereby made to the Building Inspector of the Village of Rye Brook NY,for the issuance of a Permit to install and/of rem Ave 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: fi' ff�l� Citf r �_ m SBL:-/,3a. / 7—'1—S_ Zone: —0 2.Proposed Work: 1 a► _ tf-&-L—xA C t.l 3.Property Owner: Address: r Phone#: 121 826 .4 7 ]/ Cell#: �dlr7<— email: c.a a-7 4.Master Plumber: l� (,� . �� Address: ,r+ Lic.#: Phone#: Cell#: �y�_3 7St��iemail: & Company Name: OC1t7 Address: 7 � u L N t 1� INDICATE FIXTURES&LINES TO BE ALLED 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'd Floor 4s'Floor 5t'Floor Exterior 5.*List Other Equipment/Provide Details:' kr,AAZ&, fit/�,Iv C (Sl d,�A (Notarized Signatures Required Next 2 Pages) -1- 8/12/2021 • STA14 OF NEW OM COUNTY OF WESTCHESTER ) as: kJ<-)t l Z ,being duly sworn,deposes and states that he/she is the applicant above named, (print name of individual signing as the applicant) and forth states that(s)he is he legal owner of the property to which this application pertains,or that(s)he is the iI1466 ,for the legal owner and is duly authorized to snake 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 14, Sworn to/ ,Core yme this day of OC, 6-/- ,20` � day of VU `T'� 202— t 1gn a roperty O S' a e of Applicant Ll Print Name of Property Owner Print of cant ,Notary Public lXANDRA H.MgR51{ALL otary Public } Notary PublIc,State of New Yolk CHRISTOPHER TESTA No.41FR6363711 NOTARY PUBLIC,STATE OF NEW YORK LIC.#01TE6188711 Quallfled In Westchester County: MY COMMISSION E(PIRES JUNE Oe � Commisslon Expires August 28,20 WMCHESTFA M GWN 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- 8/12J2021 BUILDING DEPARTMENT VILLAGE of RYE BgoOK OCT 15 2021 938 KING STREET RYE BROOX,NY 10573 (914)939-0668 VILLAGE OF RYE BROOK 6 ook.or BUILDING DEPARTMENT AFFIDAVIT OF COMPLIANCE VILLAGE CODE §2I6 - 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: residing at, L10 qrr(&tA J 4L V-4 (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; '!�(d iL , 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. 02 (Signature of Pr pe er(s)) (Print Name of Properry Owners) Sworn to before me this day of , 20'ql` Public) ALEXANDRA H.MARSH" Notary Public,Stateof N&wYork No.01FR6363711 Qualified In Westchester coup Commission Expires August 28,225 8/12/2021 Building Permit Check List&Zoning Analysis Address: SBL• Zone: ZS_ Use: Z 1 Const.Type: Other. Submittal Date: z ('7_ Revisions Submittal Dates: Applicant: AL Nature of Work Reviews:ZBA: �FC _ 702� PB: BOT: Other, NEED� OK ( ( ) FEES:Filing. 5` a BP: t 2-2- -+ _C/C, Legalization: ( } ( APP: Dated: ✓� Notarized: SBL: ✓ Truss I.D. Cross Connection:--' H.O.A.: ( } ( } Scenic Roads: Steep Slopes: Wetlands: Storm Water Review: Street Opening ( ) ( } ENVIRO-.Long Short: Fees: N/A: { } ( } SITE PLAN:Topo: Site Protection S/W Mgmt.: Tree Plan: Other. { } ( } SURVEY:Dated: Current Archival• Sealed: Unacceptable: ( } { } PLANS:Date Stamped: Sealed: Copies: Electronic:_Other. License: Workers Comp: Liability: ✓ Comp.Waiver. '✓ Other: O ( } CODE 7S3#: 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. ( ) ( ) 2020 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: ED Army V REQUIRED EXIS U*;G PROPOSED NOTES ` 8 2020 Area: Date: Ckcig, Fr a e Fron• Frony Sills: R�r. Main Cov: A � Ft.H Sb: Sd.H S a Tot.Imp. EL IMP: Park,z�g Height/Stories: notes, GEICO Insurance Agency, Inc. Renewal Declarations Underwritten by Homeslte Insurance For Policy Number36211629 Company of New York, a Stock Company Policy Period This policy covers the listed 1 Federal Street location(s) Boston, MA 02081 From 12:01 AM June 28, 2020 Phone number: 1-866-372-8903 Through 12:01 AM June 28,2021 (local time) To Report a Claim: 1-866-6214823 Brad Kaunitz 40 HILLANDALE RD RYE BROOK, NY 10573 Issued by Homesite Insurance Company of New York insured Location 40 HILLANDALE RD RYE BROOK NY 10573 Location ID: 000000058 Description of Dwelling 1955 Wood siding. Single family home. Primary residence Deductible- Other Covered Perils $2500 In case of hurricane loss under section 1, we cover only that part of the loss over the deductible stated. Hurricane Deductible 5% ($21250 Please refer to Important Messages Coverage Limit Premium Section i - Property Coverage A-Dwelling $425,000 $1,966.00 Coverage B -Other Structures $42,500 Included Coverage C-Personal Property $212,500 Included Coverage D-Loss of Use $127,500 Included Section II - Liability Coverage E - Personal Liability $300,000 i $171.00 Coverage F-Medical Payments to Others $1,000 $8.00 Coverage Modifications -$69.00 See Coverage Modifications on reverse side for details Additional Premium $0.00 See Additional Premium on reverse side for details Discounts -$454.00 See Discounts on reverse side for details Total $1,622.00 Authorized Representative Policy Number 36211629 HA D1 01 NY 11 17 Coverage Modifications -$69.00 Additional Limit Premium HA 23 85 1116 Limited Water Back Up and Sump Discharge or Overflow Coverage- New York $5,000 $88.00 HD-0171298 Deductible -$365.00 HO 04 20 0511 Specified Additional Amount of Insurance for Coverage A-Dwelling $34.00 HO 04 90 0511 Personal Property Replacement Cost Loss .,, Settlement $174.00 Additional Premium $0.00 Limit Premium Discounts -$454.00 Limit Premium HA 80 80 0218 Hurricane Percentage Deductible-New York 4115.00 HD-063 1101 Drive Home Discount -$180.00 HD-071 1101 Roof it Over Discount -$104.00 HD-086 0409 Welcome Home Discount -$55.00 Contracts and Amendments HO 00 03 0511 Special Form (HO 00 03 0511) HA 01 31 1116 Special Provisions-New York HA 80 66 0617 Diminishing Deductible Credit HA 90 05 0417 Amendatory Endorsement- Pollution Exclusion HO 24 93 0502 Workers Compensation Policy Number 36211629 HA Di 01 NY 11 17 Mortgagees CITIZENS SANK, N.A., ISAOA, AT SlJ CCESSORS AND/OR ASSIGNS PO Box 202060 Rorende, SC 29502 0032087546 Important Messages These Declarations are not the entire insurance policy. All information contained in the Declarations regarding the insured, covered property, coverage limits, deductibles, and premium charges is subject to the specific terms and conditions of the policy contract. Please read your policy contract and amendments carefully. We relied on the information you provided to underwrite and issue your insurance policy. Making sure the information we have about you is correct and up-to-date will ensure your home is adequately protected. Please review your"Declarations" page and check the description of your dwelling, occupancy, deductibles, coverages, and contracts and amendments. If any of this information needs to be corrected, you must advise us within 30 days of receipt. You stated that: • you occupy the insured property and do not rent out to more than two(2) roomers/boarders • no commercial or retail farming is conducted on the premises • you do not have a dog that has ever bitten a person As an Auto policyholder of one of our affinity partners, you are eligible for a discount on the base premium of your Homeowners policy. This discount is shown in the Discounts section of our declaration pages as Drive Home Discount. You are entitled to this discount as long as you remain with your current Auto Insurance carrier. If at any time that policy is cancelled and you no longer have auto insurance with this affinity partner, you will no longer be eligible for this discount. While it is your responsibility to ensure the amount of Coverage A (Limit of Liability for this structure) is sufficient to ,rebuild your home,we make every effort to assist you in determining the proper amount of coverage.Any coverage recommendation you may have received is based in part on an estimate of the Replacement Cost of your home. We may increase your Coverage A during your policy term or at renewal based on additional information we receive from an inspection of your property. Replacement Cost is generally defined as "the cost to replace a structure with materials of like kind and quality without deduction for depreciation". It is a good idea to reevaluate your home's replacement cost after you have completed any remodels, upgrades or modifications to your home. If you have made any alteration to your home, please contact us, Policy Number 36211629 HA D1 01 NY 11 17 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, 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 indic ted on the building permit. ( afore omeowner) (Date Signed) Home Telephone Number&3)— oo56-,37'7/ (Homeowner'A Name Printed) Sworn to before me this day of Property Address that requires thee building permit: 1,110-4oa le ,eocc (County Clerk or Notary Public) Ae Ir % ILr /� 1 /0 /� SHARI MELILLO Notary Public, State of New York No.01 NIE6160063 C ualified in Westchester County F Comm;^fiin Once notarized,this BP-1 form serves as an exemption for both workers'compensation and disability benefits insurance coverage. BP-1 (12/08) NY-WCB