The URL can be used to link to this page

Home My WebLink AboutBP21-047PERMIT # / 7 / DATE: 3 1/ �l EXPO SECTION 13,51 c) r% BL CK LOT. TYPE OF WORK �i OT , Ci c ✓IOVC4 JOB LOCATION /5Y Urc OWNER_0 c4v!7 IJ4be: oO � . /EST o/ CO # RArTOR _ COST FEES %I o" L*;' TCO # FEE DATE INSPECTION RECOR Q- OTHER APPROVALS ARB 93 7 9 80 BOT PB ZBA OTHER DATE INSP i FOOTING - FOUNDATION FRAMING RGH FRAMING `4 4Q '�J q INSULATION �,/ �/ PLUMBING lR RGH PLUMBING GAS 0 SPRINKLER �/ ELECTRIC [ LOW -VOLT C] ALARM AS BUILT FINAL v Epp/-/ a a1r,11r, VILLAGE OF RYE BROOK WESTCHESTE COUNTY, NEW YORK >, /0�. No: 22-091 (fertif irate of Occupaurp This is to certify that ��r6"- /2,vno ` &aeSQ2Q'K/P of, �V C� tpprnc J—( , N, having duly filed an application on )u nE a 20 a requesting a Certificate of Occupancy for the premises known as, 1 -'5 c)`d and JRQ a d , Rye Brook,NY, located in a Zoning District and shown on the most current Tax Map as Section: ' 3—'j, Block: J Lot: and having fully complied with the requirements of the Building Code and the Zoning Ordinance under Building Permit No. — 7 issued / 20 02 J, such authority and permission is hereby granted to the property owner to lawfully occupy oruse saidpremises or building or part thereof listed under the following New York State Classifications, Use: K'�/ OP e- Fa- m/I V Construction: 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 be made,nor shall the building be moved from one location to another until a permit to accomplish such change has bee bt 'ne Bu' ding Inspector. Building Inspector,Village of Rye Brook: r Date: JUN 14 2022 r-, �, `� U �C_.� ll LJUN 8 2022 For officor J ---� BUILDiNG DEPARTMENT usennl : 7 VILLAGE OF �?Y � �# ` BROOK - y BUILDING DEPARTMENT VILLAGE OF RYE BROOK ISSUED: 938 Klnc S'fRECr.Rvi:BROOK.'. t%% YtwK 10573 DATE: (914)9 3 9-116 6 8 FEE: PAUX w".rNCbroo rg APPLICATION FOR CERTIFICATE OF OCCI PANCY,CERTIFICATE OF COMPLIANCE, AND CERTIFICATION OF FINAL COSTS TO BE SUBMITTED ONLY UPON COMPLETION OF ALL WORK AND PRIOR TO THE FINAL INSPECTION •....................♦.........................................................................M.M...N.•N.M N.iN..q... Address:—/-, _._U/d Zf rL at' Z41 i _ Occupancy/Use:--/_I F�4✓y1 Parcel ID!t: 3 1 'Lone: owner I i vrvlr wterrr'i c a f Yb Address: Je 0// I1��rc( Rj P.L.;'R.A.or Contractor: �� _Address: Person in responsible charge: iL�pr a 1'r1O _Address: Application is hereby made and submitted to the gu3kkng Inspector of the Village of Rye Brook for the issuance of a Certificate of Occupancy/Certificate of Compliance for the structuretconstruction.'alteration herein mentioned in accordance with law: VI E(OF NPW YORK.COUNTY OF WESTCHESTER as: r (� lQ r' GC��I� O being duty sw urn.depows and says that he.she tesi& jt 5 (/�d tJ 1'C 1 a r� tid in &�/G fOlU F in the County of in th,State of N y that h.:+she ha.,ultin ued thc w of k at the location indicated dive.and that the actual total cost of the wok.including all site inipto%enients, labor.materials,scaffi Wing.fixed equipment,profesbiunal fees,and including the nwnctary value of any matenals and labur which may have been donated gratis was:SUyd fut die Lvnstruc`tivn Lot altetation+ut )5Ar T k r6?,9 r -% Deponent further states that he sltc has cxamin►d the approved plans of the stnicttue,work herein referred to for which a Certificate of Occupancy:Compliance is sought,and that to die best of his.bci knowtedgc and belief,the structur-etiwrk has been etected-'cumpleted in accordance w ith the appruvcd plans and any amendnimu thercto except in so far as variations therefore have been legally authoizo:4 and as erected-cvmpl.ted cumplics with the laws governing building c niouction.Depurt.nt further understsads that it shall be unlawful tot an owner to use of penny the use of any building or premises or part thereof hereafter created,ercewd,cheeped.converted o erilmged.wholly or partly.in i6 use art A tctuse until a Certificate ofOmWancy or Certificate of Compliance shall hay c been duly issued by the Building Inspector as pet 4250-1 OA.of the Code of the Village of Rye Brook. (,, Sworn to before me this�p Sworn to before me this 1� day thf 11:Z4 .20 y day of/M iQ .20 2Z/ 51yriYi�'t uT Pn7Perty UN1M Nipnure at Apo ,u t Per Niue Pr.gerty[)Ntir Ruu N at Apphar NWan Punta Nolan Public LETITIA 0`BRIEN NOTARY PUBLIC, State of New York No. 01OB4975928 Qualified in Queens County 2 Z/ Commission Expires Dec. 26, 20_ �yE aRO '9a2 BUILDING DEPARTMENT [1jlUILDING INSPECTOR STANT 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 :— a � DATE. -2 U PERMIT#J ISSUED: J \I`1 SECT: �J.2 LOCK: - LOT:' LOCATION: l </a c`\ Jl�' 1 �/C�� (CCUPANCY: ❑ VIOLATION NOTED THE WORK IS ACCEPTED ❑ REJECTED/REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ NATURAL GAS ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL [ OTHER �yE BRC��. O� y� cu � • �9�2 BUILDING DEPARTMENT ❑BUILDING INSPECTOR ASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK CODE ENFORCEMENT OFFICER 938 KING STREET • RYE BROOK,NY 10573 (914) 939-0668 FAX (914) 939-5801 www.Uebrook.org - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS 06c D E: (J PERMIT# 2 ` - "- ISSUED: ' �ECT: BLOCK: LOT: LOCATION: 2-v� \ 1 OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... u ACCEPTED ❑ REJECTED/ REINSPECTION ❑ SITE INSPECTION / REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION Cl UNDERGROUND PLUMBING NOTES ON INSPECTION: ROUGH PLUMBING `❑ ROUGH FRAMING ❑ INSULATION ❑ NATURAL GAS ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER w i .r ., Old 7 00 6 ol w G� A � 4 �- 0 w w Z o Z 0 < C6 en ON* oc Ono^^1 r y CL g �. to _ �i�i �-'� R=�i-i ♦+��i��i�w��i�i��i�i�i�i�i��i��3�� `��s�s�� !,� `��1�� FD CFC� 1EW[E 0j BU E NT VILILA' OF RYE OK APR 2 7 2021 938KTNGSWETRYEB NY 10573 (914)9 939-5801 VILLAGE OF RYE BROOK BUILDING DEPARTMENT ore�y ---- .._._........ _.---------------- ELECTRICAL PERMIT APPLICATION Westchester County Master Electricians License Required FOR OFFICE USE ONLS IMP 6t �"C) EP#: �l—`Ci APR 2 7 2021 Approval Date: Permit Fee: S Approval Signature: Other: Disapproved: (fee-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/6r rem ve electrical equipment, wiring, fixtures,or to perform other high or low voltage electrical work as per the detailed statement described below. The applicant & property owner, by signing this document agree that all electrical work performed will be in conformance with all applicable Federal,State,County and Local Codes. -, 1.Address: - C ��i-j� ed SBL: 31.�.7Y' one:/C_/�� 2.Property Owner: ICio 1 ez Tern O Address: Phone#: // — •-�/ KO Cell#- email: 3.Master Electrician:_ YN lc-- Address: ( ✓ (,! Lic.#: �Phone#:! _Cell#: �-f3 email: „- Company Name: Cj C L i lic ! Address: 4.Proposed Electrical Work/Fixture Count: STATE OF NEW YOM COUNTY OF WESTC1 ESTER �Gto� Tt't'j1 O J Y- being duly sworn,deposes and states that he/she is the applicant above na and does further (print mime 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 arOttecr,contractor.agent,attomcy,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&Ruilding Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances and regulations. L Sworn to before me this Z 3 OLDSworn to before me this AC114 ya of r`t - 2 day of Z 20 _ ,. , �S1 ature of Property Owner Tr'_ � Si t Pa��r hZ' -�11: a Print N �Property Owner Print Nat a of Appli t N ry ublic JOHN DICANIO No Public MARY SLATER NOTARY PUBLIC STATE OF NEW YORk WESTCHESTER COUNTY NOTARY PUBLIC-STATE OF NEW YORK LIC#01D14977768 No. 01 SL6130868 COMMISSION EXPIRES 2/11,7(,23 C)ualified in Westchester County ,i,y Commission Expires 07-25-20219 Westchester Rockland Electrical Inspection Services, Inc. Phone: 91U4-347-3595 1 DO NOT WRITE HERE-FOR OFFICE USE ONLY 43 North Lawn Avenue Lr`y Fax: 14-347 3596 Elmsford NY 10523r a �i 711PERMIT NO.. TEMP k DATE " C CITY OR VILLAGE ZIP CODE TOWNSHIP COUNTY STREET AND NO.OR ROAD POLE NUMBER BETWEEN WHAT TWO CROSS STREETS IS PREMISES LOCATED? SECTION BLOCK LOT OCCUPANT'S NAME BUILDING OCCUPANCY OWNER'S NAME AND ADDRESS HOME TELEPHONE NUMBER CURRENT SUPPLIED BY FROM THEIR OFFICE WORK TELEPHONE NUMBER LIST BELOW ALL EQUIPMENT WHICH YOU INSTALLED NUMBER OF OUTLETS NO.OF FIXTURES& MOTORS HEATERS OFFICE USE LOCATION LAMP RECEPTACLES ONLY SIDEWALL SWITCH INCADE FLUORE NO. H.P.EACH NO, WATTS EACH INSPECTION OUTSIDE BASEMENT 1-FL. 2-FL. ni J U ArK Z I 3-FL. VIL GE OF AYE 13ROOK REMARKS:LIST OTHER ELECTRICAL DEVICES NOT SET FORTH ABO : BUILDING DEPAR/MENT 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❑ ADDITIONAL❑ EXPOSED❑ CONCEALED❑ MUST ENTER APPLICANTS IDENTIFICATION NUMBER SERVICE ENTERS BUILDING OVERHEAD❑ UNDERGROUND❑ L-Lj- I I I I AVOID DELAYS BY GIVING FULL AND ACCURATE INFORMATION.ALL SPACE MUST BE FILLED IN OR APPLICATION MAY BE RETURNED. NAME OF COMPANY DATE OF APPLICATION SIGNATURE OF APPLICANT X STREET ADDRESS TELEPHONE NO. - CITY OR POST OFFICE T;;C..E LICENSE NO.WHEN APPLICABLE WESTCHESTER ROCKLAND ELECTRICAL INSPECTION SERVICES,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: Pinto Electric Co Inc Victor&Annemarie Paterno 109 Maple Avenue NY, Rye 10580 Located at: 15 Old Orchard Rd Rye Brook, NY 10573 Certificate Number: 1033962 Section: 135.27 Block: 1 Lot:3 BDC: Permit Number: EP:21-102-BP:21-047 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: 15 Old Orchard Rd 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 04/05/22 Name Type Quantity Switch Single Pole ------- 1 Floor Heat ------- 1 Receptacle GFCI ------- 1 Fixture LED ------- 4 Exhaust Fan ------- 1 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. Y �o o �n r N fq c Q � o U s � r > p, cc s '�'.W � 4 z z •� � � E.r y E 0 Z z _ en � ^^�•ti . ono � ; F. v� A w C600 on o i O WV1 WO� Z G F'" ; t i i r_l � U m Z Z enrn a o O CN Q z Z Oc rn sz A aZ i4 g 4 a c o w N ;, � a aw •• c 1.06 O ze � U a 96 60� � ° kn U A O � 9 � 3 R [E C E ME BUILDING DEPARTMENT VILLAGE OF RYE BROOK MAY 18 2021 3 938 KING STREET RYE BRooK,NY 10573 VILLAGE OF RYE BROOK (914)939-0668 FAx(914)939-5801 BUILDING DEPARTMENT wNvv,.rvebrook.or,, -� PLUMBING PERMIT APPLICATION FOR OFFICE USE ONLY BP#: Q I L Lf'�_ PP#: C;)/0k0 MAY 1 9 2021 Approval Date: Permit Fee: $ Approval Signature: Other: Disapproved: (fees are non-refundable) Application dated. `I `1 21 is hereby made to the Building Inspector of the Village of Rye Brook NY, for the issuance of a Permit to install and/or remove Plumbing as per detailed statement described below. The applicant&property owner,by signing this document agree that said plumbing work will be in conformance with all applicable Federal.State.County and Local Codes.1.Address: LS 0,\C� Cr LI-0,d SBL: 136-i a7r/-3 Zone:/e —115- 2.Proposed Work: E4c 1 b� , rin�oc�Z t l S n 1L 4 71 3.Property Owner: k cj-or �l c -n o Address: 1 j` I 'Orc-P Phone#: c?► y-ci 'I - j 1 d'L' Cell#: email: L/i t ,�1 16D,5 o I • Co✓Yi 4.Master Plumber: dy1%c N,4j PtA N —r,n o Address: 1I%ss Lic.#: I I l0 5 Phone#: Cell#: `� -`!9 -y 37 S email: M P2 II fur, o i 1 w M Company Name:V 0jk: a I✓1'T1�5mb Vl�" Address: L/1 K t rc��Ic,!,n 54 INDICATE FIXTURES& LINES TO BE INSTALLED AS PER THE FOLLOWING SCHEDULE: Location Water Urinals Druiking Sinks Showers Bath Laundry Domestic Fire Sanitary Natural/ Other" Total Closets Fountains Tubs Tubs Service Service Sewer LP Gas Basement 1 st Floor 3® 2nd Floor _31a Floor 4 Floor 5 Floor Exterior 5.*List Other Equipment/Provide Details: \r\G\\ QQt NCG�1�_ (Notarized Signatures Required Next 2 Pages) -1- 3/21/19 STATE OFNEW YORK. COUNTY OF WESTCHESTER ) as: M I(,k(K l 9C�I ea('I No .being duly sworn,deposes and states that he/she is the applicant above named, (print name of individual signir&s 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 4Ck e�4 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 9 Sworn to before me this l9 day of Q .20�_ day of 20 4 Signature of Property Owner Signature of Applicant Y/Z fo ri-- Pa-)- r y)0 wIl c.hc;cl 1�C�Ieg6Jo 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- 3/21/19 BUILDING DEPARTMENT p VILLAGE OF RYE BROOK 938 KING STREET RYE BROOK,NY 10573I MAY 18 2021 ID (914)939-0668 FAX(914)939-5801 www.ryebr,�ok. r VILLAGE OF RYE BROOK ;T- BUILDING DEPARTMENT AFFIDAVIT OF COMPLIANCE VILLAGE CODE §216 NORM 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 YOM COUNTY OF WESTCHESTER ) as: � � � 1 ) / 31, V i�"Ina' y, cf f'( "U , residing at, /5 (Print name) (Addre„\%hcic w t li�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; 5 rLy-,cGs),cl �0(-\ J , Rye Brook, NY. (Jol, ddl 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 of Property 0"'ner(s)) V/( -6 1' �a/7� r ►� y .�Y (Print Name ol'Properl- O\\ncr(s)) Sworn to before �me this �'�-f g day of / Q�) , 20 :W (Nolan,Public) -3- 3/21/19 Building Permit Check List&Zoning Analysis Address: 1-5 �i—b rho� � -Z r� _ SBL: 3-C, 2-7 — l Zone- l S Use: Z o Const.Type: Other. Submittal Date: l2 Revisions Submittal Dates: Applicant: 0 Nature of Work I JILE-0—s 0(2— Reviews:ZBA: MAR 1 12021 PB: BOT: Other. OK ( ( ) FEES:Filing. - BP: t S 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 Mgmt.: Tree Plan: Other. ( ) ( ) SURVEY:Dated: Current: Archival: Sealed: Unacceptable: ( ) ( ) PLANS:Date Stamped Sealed Copies: Electronic: Other. ( ) ( ) License: Workers Comp: Liability: V" 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. (Jl ( ) 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: REOUIRED EXISTING PROPOSED NOTES APPROVED Am: Data-MAR t1 2021 Circle: _ Fie Front: Front: Sees: Fir. Main Cov Accs.Cov Ft.H Sb Sd.H Sb: Tot. EL IMP: Par ' Height/Stories: notes: PREFERRED MUTUAL INSURANCE COMPANY Preferred One Preferred Way New Berlin NY 13411 Mutual POLICY ISSUED ON THE CO-OPERATIVE PLAN MORTGAGEE BILL LiveAsgurer- HOMEOWNER DECLARATION AMENDED EFFECTIVE 11/24/2020 Policy Number: PHO 0100 78 04 41 Agent: DENNIS F MCCARTHY INC Agent Code: 002 31 36700 Address: HAWTHORNE NY 10532 Phone Number: (914) 769-0417 Policy Period: from 09-25-2020 to 09-25-2021 12:01 A.M. standard time at the mailing address of the named insured as stated herein. N ANNEMARIE W PATERNO & Replacement or Renewal Number of: PHO 0100780441-2 s u VICTOR F PATERNO JR R 15 OLD ORCHARD R D This replaces all previously issued policy declarations, if any. This policy applies only to occurrences or g o RYE BROOK NY 1 0573- 1133 losses which happen during the policy period and for which a limit of liability or premium charge is shown. J Described location covered by this policy (if other than address above) m 0 COVERAGES & LIMITS A. B. C. D. L. M. DWELLING OTHER PERSONAL LOSS OF USE PROPERTY PERSONAL MED. PAYMENTS STRUCTURES PROPERTY DEDUCTIBLE LIABILITY PERSON ACCIDENT 731,000 73,100 511,700 146,200 1,000 500,000 5,000 1 25,000 FORMS & DESCRIPTION PREMIUM FORM3 02/00 Special Form - 3 3099.00 ML147 01/00 Punitive Damage Exclusion INCLUDED ML53AB 01/02 Extension Of Property Coverage INCLUDED ML0483 01/99 Calendar Date or Time Failure Exclusion INCLUDED ML0667 01199 Coverage for Computer Error Excluded INCLUDED ML435 01/01 Pollution Liability Exclusions INCLUDED UMNYSCHD 09/18 Personal Umbrella Schedule of Underlying Insurance INCLUDED UM1731 09/08 Personal Umbrella Amendatory Endorsement New York INCLUDED SM100 04/91 Third Party Designee INCLUDED SM-26 06/93 Notice of Automatic Renewal Coverage Increase INCLUDED MLOO84 03/10 Amendatory Endorsement - New York INCLUDED ML4917 12/08 Water Exclusion Endorsement INCLUDED DN182RA 05/16 Important Credit Disclosure Notice New York Renewals INCLUDED PM51AB 01/18 Amendatory Endorsement INCLUDED UMPMNY 06/17 Personal Umbrella Liability Coverage Amendatory INCLUDED MLOO90 12/98 Workers Compensation INCLUDED ML0691 04/04 Limited Property Coverage for Loss Caused by Fungi INCLUDED ML145 01/00 Expanded Replacement Cost Terms 10.00 ML55 09/01 Replacement Value 55.00 ML184 01/00 Inflation Guard - Option 4 52.00 MLWD 01/18 Water Damage - Sewers and Drains 55.00 Thank you Joa in,buhi.ng with Ptizievfed Mutuat ADDL PREMIUM DUE 33.00 TOTAL PREMIUM $2,750.00 ADDITIONAL INFORMATION ON REVERSE SIDE THIS IS NOT A BILL RATING INFORMATION: PROT CL P PR GRP 010 TERR 149 PI EDGES CONSTRUCTED INTL: 1970 CONSTRUCTION F $/FAM/APT 1 DWG USE PRIMARY change: UPDATE UMBRELLA- CARRIER & ADD VEHICLE Description of PMHD(10-14) COUNTERSIGNATURE: UPLD 946389901 x PHO 0100780441 14/09/2020 UCL INSURED'S 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'compensatdon 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 appr,-o-priate box): LJ 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 j obsite)for work indicated on the building permit,or if appropriate,file a CE- 200 exemption form; OR ♦ have the general contractor, performing the work on the 1, 2, 3 or 4 family, owner-occupied residence (including condominiums)listed on the building permit that I am applying for,provide appropriate proof of workers'compensation coverage or proof of exemption from that coverage on forms approved by the Chair of the NYS Workers' Compensation Board to the government entity issuing the building permit if the project takes a total of 40 hours or more per week(aggregate hours for all paid individuals on the jobsite)for work indicated on the building permit. (Signature ofHomeowner) (Date Signed) �N�ertia n c�� t�y Home Telephone Number '7 (CA -{3 7-'T(� (Homeowner's Name Printed) Sworn to before one this ks day of Property Address that requires the building permit: VS CAA, Clv-&,ea�A Q k _ i' ;� • ounty Cl otbry P i c) ALEXANDRA H.F NK(;�►�1'�h�Ul T Notary Public,State of New York No.01FR6363711 Qualified in Westchester County I Commission Expires August 28,20-L. 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 D ECENED MAR - 9 2021 VILLAGE OF RYE BROOK BUILDING DEPARTMENT Bathroom Main 14 1 . Floor 0 ' o Z 0 1 ` � mG of C W - CIP O a a ~ Q z W o / W m Qsq ft f -Itj frL N G m U) / q