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Home My WebLink AboutBP20-273RMIT # S�ECTI ON TYPE OF WORK JOB LOCATI®N , OWNER_-_ CONTRACTOR_ J sT.# < TCO # �n273 DATE: Ia QEXP;� BLOCK LOT F DA Lg-343(p FEE DATE ._ F INSPECTION RECORD DATE INSP FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING RGH PLUMBING GAS -- SPRINKLER ELECTRIC LOW -VOLT El ALARM AS BUILT 0 FINAL 7J -fig //ff// Liporic lusly L%%w , Pa1 -Ol cml/ C �reSCQnZo E%c.�,-iCctl ion aC 'r OTHER APPROVALS 'ARB BOT PS ZBA OTHER VILLAGE OF RYE BROOK WESTCHESTER COUNTY, NEW YORK No: 22-030 Certiftra.te of Orrupaurp This is to certify that Er) C & C Y—!_f _ of, Y-C 9KOO Ky /V y having duly filed an application on IJLa 2z�l 20 f requesting a Certificate of Occupancy for the premises known as, Rye Brook,NY, located in a PUJ0 Z oll i n a District and shown on the most current Tax Map as Section: Block: I Lot: a , and having fully complied with the requirements of the Building Code and the Zoning Ordinance under Building Permit No. , issued )0'2 )`-1 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 New York State Use Classification of: - (one — Fam/ L/y for the following purposes: 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 b ,n the building be moved from one location to another until a permit to accomplish such change has been in d from the�4' gtor.Building Inspector,Village of Rye Brook: ate: �R ` `� ��Z D V $jJIItD NT For office use onE T , PaRmT#� ,�-' 73 VaF RYE BROOK ISSUED:A>)SEP 2 4 2021 38 KMG S� BROOK, N,, YORK 10573 DATE:(914) 8. 939-5801 FEE: .6' / IC'3— PAua.ef VILLAGE OF RYE BROOK ,o 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 #iiitifii!!ifliiiiit•iiiiiiiitiitlifffiflfffitf#ltffififfitiiiflfiflflitiiiiiiiiiiiiiititittiifltfttt#t#titfffffft##ttf!!!!ti Address: $ Q6F- e-AaF" YF '(-3IeW rvY IOS-431/Use: �C,401 Parcel ID#: /a /. Q T /3 9 zone:A46 Owner. 6W IC 731CU&e- Address: /$ RaSC=�iu� 2.+t� err/c �trl�gar � REJRA. or Contractor. 14>�nr •rRirrS etc Address: 3a ac FAoem Pc c ra la c'1- Person in responsible charge: rf Ier-0L AB6ci4j5ki Address: acn _AaM -MA, r at', 9 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: C-A!< e being duly sworn,deposes and says that he/she resides at IS3/laafc o l 3 (Print Name of Applicant) (No.and Street) in R)-, 11 0 oc k in the County of in the State of iv."' ,that (City/Town/Village) he/she has supervised the work at the location indicated above,and that the actual total cost of the work,including all site improvements,labor, materials,scaffolding,fixed equipment,professional fees,and including the monetary value of any materials and labor which may have been donated gratis was:$ l r o o O for the construction or alteration of: t SE1 Eu�4- /2 ✓ch 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 structurelwork 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 �V.i�llage of Rye Brook. Sworn to before me this C) \ Sworn to before me this day of ��Q C"� , 20 a` day of 720 Signature of Property Owner Signature of Applicant Vnni �y�l C �1 C�C�+✓� Name of Property Owe Print Name of Applicant Now Public SHARI MELILLO Notary Public Notary Public,State of New York No. 01 ME6160063 3 z 1 1 1) Ouali,ied in Westchester County rr�� Commission Exr)irPs J^,i lanr 29 20 a 7 QyC BRC��. • j9�2 BUILDING DEPARTMENT ❑BUILDING INSPECTOR SSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK ❑CODE ENFORCEMENT OFFICER 938 KING STREET • RYE BROOK,NY 10573 (914) 939-0668 FAx (914) 939-5801 www.aebrook.org - - - - - - - - - - - -- - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS : ` !4.--� DATE: LJ �✓�� PERMIT# � ISSUED: L I ECT: BLOCK: LOT: 114. LOCATION: V ' � '` OCCUPA ❑ VIOLATION NOTED THE WORK IS...'10�CCEPTED ❑ REJECTED/REINSPECTION ❑ SITE INSPECTION REQUIRED 0 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 #/0 OTHER Y �yE BRC��' 04 2m w � 1982 BUILDING DEPARTMENT ❑BUILDING INSPECTOR -'E3%A$SISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK ❑CODE ENFORCEMENT OFFICER 938 KING STREET • RYE BROOK,NY 10573 (914) 939-0668 FAX (914) 939-5801 WWw.rXebrook.org - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS : + y� DATE: 2 PERMIT# U � ISSUED: �Z �ECT: BLOCK: LOT: LOCATION: OCCUPANCY: ( LJ ❑ VIOLATION NOTED THE WORK IS... ACCEPTED ❑ REJECTED/REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING C ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: �OUGH PLUMBING ❑ ROUGH FRAMING INSULATION NATURAL GAS L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING CROSS CONNECTION ❑ FINAL ❑ OTHER ci rq C N OC y w x a ' CC _ tAEs vof W p z c a W LU 3 a 3Y C Q U Fr CD r � en �'"' �C " U A � � a r = a • Er Eno Grp �' z °C z F � � � E- •• $: v� z u w x � wz BUILDING DEPARTMENT VILLAGE OF RYE BROOK JAN 14 2021 938 KING STREET RYE BROOK,NY 10573 VILLAGE OF RYE BROO (314)939-066Ax(914)939-580I BUILDING DEPARTMENT w ww.ftbl-oo k.urn, ELECTRICAL PERMIT APPLICATION Westchester County Master Electricians License Required FOR OFFICE USE ONLY BP#: CDO _Q?3 EP 4. JAN15Z011 '10_ Approval Date: Permit Fee: $ Approval Signature: Other: Disapproved: (fees are non-refundable) Application dated, is hereby made to the Building Inspector of the Village of Rye Brook NY,for the issuance of a Permit to install and1dr remove electrical equipment,wiring,fixtures ,or to perform other high or low voltage electrical work As per the detailed statement described below. The applicant & property owner, by signing this document agree that all electrical work performed will be in conformance with all applicable Federal,State,County and Local Codes. 1 1.Address: I� g O�'e ),a n� SBL: �a o �J / r 3 9 Zone: 'A 2.Property Owner: E F I e JE) 1 C l-e-r Address: 110 Phone#:qI y— 49 z1—;�y(:5� Cell#: email: 3.)Master Electrician: Qk'l t � i4ese— Address: ) 4Q Sul Lic.t 1'_> C) Rhone#: 1 �rr`II Cell#: 1��b�email: Company Name: C re-r ce Yt bD Cat({r►aL( C L)1+-C'L+'A6dr ss 00 3�<K DA,h ki N 4.Proposed Electrical Work/Fixture Count: _l STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: ,being duly sworn,deposes and states that he/she is the applicant above named,and does further (print name of individual signing as the applicant) state that(s)he is the legal owner of the property to which this application pertains,or that(s)he is the for the legal owner and is duly authorized to make and file this application. (indicate architect.contractor.agent.attome F,etc.) The undersigned further states that all statements contained herein are true to the best of his/her knowledge and belief,and that any work performed,or use conducted at the above captioned property will be in conformance with the details as set forth and contained in this application and in any accompanying approved plans and specifications,as well as in accordance with the New York State Uniform Fire Prevention&Building Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances and regulations. Sworn to before me this Sworn to before me this day of ,20 day ,20 Signature of Property Owner t pplicant Print Name of Property Owner Pr' t Na a of Applicant Notary Public Notary Public �tnq Westchester Rockland Electrical Inspection Services, Inc. phone: 914-347-3595 DO NOT WRITE HERE—FOR OFFICE USE ONLY 43 North Lawn Avenue K Fax: 914 347-3596 Elmsford, NY 10523 R� BUILDING PERMIT NO. TEMP N DATE CITY OR VILLAGE'J _ DECODE ! TOWNSHIP COUNTY STREET AND No.OR ROAD l POLE NUMBER .t (l BETWEEN WHAT TWO CROSS STREETS IS PREMISES LOCATED? SECTION BLOCK LOT -- OCCUPANTS NAME- BUILDING OCCUPANCY QWNER'S NAME AND ADDRESS Hf31�1�� PHp�IE t. BER,�� I : ice Ll Lf( N CURRENT SUPPLIED BY FROM THEIR OFFICE WORK TELEPHONE NUMBER LIST BELOW ALL EQUIPMENT WHICH YOU INSTALLED NUMBER OF OUTLETS NO.OF FIXTURES& MOTORS HEATERS OFFICE USE LOCATION LAMP RECEPTACLES ONLY SIDEWALL SWITCH INCADE FLUORE NO. H.P.EACH NO. WATTS EACH INSPECTION OUTSIDE BASEMENT �I P 1"FL 2-FL pill 3-FL VILLAGE OF RYE BROOK 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 APPUCANT.OWNER,OR AUTHORIZED AGENT AGREES TO ALL THE ABOVE TERMS AND CONDITIONS AS SET FORTH FOR.THE APPLICATION. SIZE OF SERVICE FEEDERS CHARACTER OF WORK NEW❑ ADDITIONAL f 1 EXPOSED❑ CONCEALED❑ MUST ENTER APPLJCANTS IDENTIFICATION NUMBER SERVICE ENTERS BUILDING OVERHEAD❑ UNDERGROUND❑ 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 1 �] s10NATURE OF APPLICANT^ STREET ADDRESS TELEPHONE NO. CITY OR POST OFFICE 1 ! ZIPLICENSE NO.WHEN APPLICABLE IF WESTCHESTER ROCKLAND ELECTRICAL INSPECTION WRE1a,,,V,,,S,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: C Crescenzo Electric Eric Bickler PO Box 388 NY, Mohegan Lake 10547 Located at: 18 Rose Lane Rye Brook, NY 10573 Certificate Number: 1029193 Section: 129.25 Block: 1 Lot: 1.39 BDC: Permit Number:EP:21-012-BP:20-273 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: 18 Rose Lane Rye Brook,NY 10573 Basement 1st Floor 2nd Floor 3rd 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 07/22/21 Name Type Quantity Switch Single Pole ------- 4 Fixture-Luminaire Incandescent ------- 4 Motor 1 hp-50hp ------- 1 Exhaust Fan ______ 1 Fixture-Luminaire Recessed ------- 2 This Certificate has been approved by Westchester Rockland Electrical Inspection Services. This certificate may not be altered in any way. `�—7��G This certificate is valid for work performed before date of inspection only. 4 ■ W N N 0 0 N � J all 6 z o co ~ ~ tir, Y C4 CO 3 Lia x N � � r rr , p wraw i r l S O f v O gz >- co OC o z a V A � cl, ~ Q rn Cl, Z o w o" r Gii = U w r Z U C6 a 0o C7 A G7 w o °o F. : I C6 ri �1 Gar = w r BUILDING DEPARTMENT VILLAGE OF RYE BROOK JAN 19 2921 938 KING STREET RYE BROOK,NY 10573 (914)939-Qb6 . AX'(914)939-5801 www. r ok.org PLUMBING PERMIT APPLICATION FOR OFFICE USE ONLY BI' #: a. .3 PP #: Approval Date: J AN 2 0 2021 Permit Fee: $ Approval Signature: Other: Disapproved: (fees are non-refundable) Application dated, `7 is hereby trade to the Building Inspector of the Village of Rye Brook NY, for the issuance of a Permit to install an8jor remove Plurnbing as per detailed statement described below. The applicant.&property owner,by sighing this document agree that said plumbing work will be in conformance with all applicable Federal,State,County and Local Codes. 1.Address: l8 Cuss Lrv_ Zone: AUD 2.Proposed Work: Nfsif �PF��o✓sc i�GZ��rjJ r�vT /�5 �f N"� r.-''>. 7J��,�,/f'7 3.Property Owner: C-elC 13/CkrCre- Address: /$ �es�-c�wE- RyC-t3/lao,r rvyiof 3 Phone#: 7/V y7V o?y6,9 Cell#: 9/S! ` YV ayCa email: e-Rlc r3iCL-eey[euKAilou. eo,-1 4.Master Plumber: gjt Sst- S rJ/T/l Address:_ 7a RO m90040AC by taS*Y j Lic.#: /1/Z& Phone#: ByS` y9y- 7y7 f Cell#: email: W 4�MsrRvc t .n� c,row Company Name: ,4tz iiucLx'Vy- /?k--v rt,4 ,c,L Address: ?� �9KE"S�Qc INDICATE FIXTURES& LINES TO BE INSTALLED AS PER THE FOLLOWING SCHEDULE: Location Water Urinals Drinking Sinks Showers Bath laundry Domestic Fire Sanitary Natural/ Other` Total Closets Fountains Tubs Tubs Service Service Sewer LP Gas Basement 1 ` 1st Floor 2nd Floor 3 Floor 4 Floor 51 Floor Exterior 5. *List Other Equipment/Provide Details: (Notarized Signatures Required Next 2 Pages) 3/21/19 STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: sue" S01117 r� being duly sworn,deposes and states that he/she is the applicant above named, (print name of individual signing as the applicant) and further states that(s)he is the legal owner of the property to which this application pertains,or that(s)he is the ?L44-191>'I✓ti lane�/ z a2 for the legal owner and is duly authorized to make and file this application. (indicate architect,c�atrac�r,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 kefore me this day of ,20 day okPMVa ,20� Signature of Property Owner Signat4e of Applicant Print Name of Property Owner Print Name of Applicant Notary Public Notary Public This application must be properly completed in its entirety and must include the notarized signature(s) of the legal owner(s) of the subject property, and the applicant of record in the spaces provided. Applications not properly completed in its entirety and/or not properly signed shall be deemed null and void and will be returned to the applicant. -2- 3121/19 BUILDING DEPARTMENT VILLAGE OF RYE BROOK JAN 19 2021 938 KING STREET RYE BROOK,NY 10573 (914)939. x(914)939-5801 AFFIDAVIT OF COMPLIANCE VILLAGE CODE V 16 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 PLUMPING PERMIT APPLICATION SUBMITTED WITHOUT THIS COMPLETED AND NOTARIZED FORM WILL BE RETURNED TO THE APPLICANT.. STATE OF NEW YORK, COUNTY OF WESTCHESTER ) as: 31, e�'c R1 c'kCEy2 , residing at, (Print name) (Address where t OLI lip C) 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; le ,eo5e c'qN67—_ , Rye Brook, NY. (Job Addressl 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. (Signature ofProperh ()%\ncr(s)) Fes/c `/3/ckl�`U (Print Name of Property Owner(s)) Sworn to before me this day of , 20 (Notary Public) _3. 3121/19 Building_Permit Check List&Zoning Analysis Address: C "ib SBL: t ZS •2 — L — I . l Zone: Use: Const.Type: Other: Submittal Date: `i Z Revisions Submittal Dates: Applicant: = -t-- rIZ t C PL i-F /L Nature of Work: 1 t.S t4 SP R ti' eview •23A: S E P 3 2020 PB• BOT: Other. NE ( ) FEES:Filing: 7 BP: Z Z C/O: Legalization: ( } ( �/APP. Dated: ✓ Notarized: SBL: Truss I.D. Cross Connection: " H.O..A..: ( } ( ) Scenic Roads: Steep Slopes: Wetlands: Storm Water Review: Street Opening. ( } ( ) ENVIRO:Long Shore Fees: N/A: ( } ( ) SITE PLAN:Topo: Site Protection S/W Mgrnt.: Tree Plan: Other. ( } ( ) SURVEY:Dated: Current: Archival;- Sealed: Unacceptable: ( } ( ) PLANS:Datotamped Sealed�,,1 Copies Electronic: Other. ( . (� License: V Workers Comp: Liability V Comp.Waiver: Other: ( } O 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: PLUMMNG 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: ( ) ( ) 2017 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: APPROVED REQUIRED EXISTING PROPOSED NOTES A= Date: 2020Circle: Fron Front: Front Sides fir. Main Cov Acrs.Cow. FL H S Sd,H/Sb: To�Imv: FL IMP; kad=g: Height/Stories: notes: Laura Petersen From: Laura Petersen Sent: Thursday, September 3, 2020 8:52 AM To: 'ERICBICKLER@YAHOO.COM' Subject: Building Permit for 18 Rose Lane Good morning, The building permit application has been approved by the Building Inspector, before I can issue the building permit the following items must be submitted to our office, 1. General contractor's contact name & phone number. 2. Copy of general contractor's valid Westchester County Home Improvement License. 3. General contractor's valid liability insurance (the Village Of Rye Brook must be the certificate holder) 4. General contractor's valid workers compensation on a NY State Board form (C105-2 or U26.3) 5. Building permit fee $225.00 (due once permit is issued and ready for pick-up) Thank you! Have a great day! 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 luetersen a@ryebrook.org 1 �� . �* �� _� � � � I �► 0 L a v - � t. �� a 1 � � � � � � �� .a r ��1 j� rw `• �� _-.. �� _' � � � V � � AC R0® CERTIFICATE OF LIABILITY INSURANCE FDATE(MMIDDIYYYY) 1 2/1 012 0 2 0 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTA T John M. Glover Agency PHONE Susan De Franco FAX P.O. Box 700 •203-497-3719 AIc No:203-230-0885 Norwalk CT 06852 AoDRESs: sdefranco 'ahnm IDver.com INSURERS AFFORDING COVERAGE _ NAICN INSURER A:Main Street America Assurance Company 29939 _ INSURED SOBOTRI.01 INSURER B:NGM Insurance Company 14788 Sobot Trims LLC 32 Old Farm Road INSURERC:LM Insurance Corp 42404 Wilton CT 06897 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1593740043 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL UBR POLICY EFF POLICY EXP LTR POLICY NUMBER IMMIDDIYYYYI (MMIDDIYYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY MPT9101J 7/31/2020 7/31/2021 EACH OCCURRENCE $1,000,000 CLAIMS-MADE OCCUR PRMAGE ToRENTED EMISES Ea occurrence $500.000 MED EXP(Any one person) $10,000 PERSONAL 8 ADV INJURY $1,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2.000,000 POLICY�JECOT 1 A I LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ B AUTOMOBILELUUBILITY B1T9101J 5/24/2020 5124/2021 Ea BINEDl SINGLE LIMIT $500,000 ANY AUTO BODILY INJURY(Per person) S OWNED X SCHEDULED BODILY INJURY Per accident S AUTOS ONLY AUTOS ( ) H HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DIED RETENTION$ $ C WORKERS COMPENSATION WC5-31S-613702-039 8/29/2020 8/29/2021 X H- AND EMPLOYERS'LIABILITY YIN STATUTE ER _ ANYPROPRIETOR/PARTNERIEXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICERIMEMBEREXCLUDED? r NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If Yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 1D1,Additional Remarks Schedule,may be attached if more space Is required) 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 AUTHORIZED REPRESENTATIVE Rye Brook, NY 10573 9)1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 4 NYSIF New York State Insurance Fund WESTCHESTER ONE,44 SOUTH BROADWAY, 10TH FLOOR,WHITE PLAINS,NY 1 060 1-441 1 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE 0 � ^^^^"^ 454527141 JOHN T OSTHEIMER AGENCY INC CIO JOHM M GLOVER AGENCY PO BOX 700 ' NORWALK CT 06852 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER SOBOT TRIMS LLC(A CT LLC) VILLAGE OF RYE BROOK 32 OLD FARM RD 938 KING STREET WILTON CT 06897 RYE BROOK NY 10573 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE W2521611-0 896486 08/22/2020 TO 08/22/2021 12/10/2020 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2521611-0, 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:/NVWW.NYSIF.COM/CERTICERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THIS POLICY DOES NOT COVER THE SOLE PROPRIETOR,PARTNERS AND/OR MEMBERS OF A LIMITED LIABILITY COMPANY. 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: 907320960 U-26.3