HomeMy WebLinkAboutBP21-082PERMIT # &�1— D8 v� _ DATE: p(P
SECTION a), 3 BLOCK LOT
1 i %/- / _ I _ 77
TYPE OF WORK
JOB LOCATION
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OWNER/—OZI/S �LQ: i zz ? � S)at7i t l(4.r; zzo /y)39&- 9l010
CON RACTUR /� 010111)s .PLC - 01.I zzG�y/y)39ro-9�o0l0
. COST ci 0 FEE '� A
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FEE ATE a: 23
TCO # FEE DATE
INSPECTION RECORQ
DATE I NSP
FOOTI N G
FOUNDATION
FRAMING
RGH FRAMING
INSULATION
PLUMBING
RGH PLUMBING
GAS 0
SPRINKLER _
RIC
LOW -VOLT
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S BUILT r7
FINAL
OTHER APPROVALS
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PB
ZBA
OTIiER
VILLAG OF RYE BROOK
WESTCHES% COU1'TY, NEW YORK
NO: 23-06:3
Certificate of Occupaucp
This is to certify that LD l'S &,2r1zza � :�w7lcC tarl'77c
of, RUe &'C)C-)V—1 IV y , having duly filed an application on
1ik:*-LAar-(A �20 3 requestingLa Certificate of Occupancy for the premises known as,
I�n �Ju mla Rye Brook,NY, located in a Zoning
District and shown on the most current Tax Map as Section: ,_S. Block: Lot:
and having fully complied with the requirements of the Building Code and the Zoning Ordinance under Building
Permit No.(:;?) /-V8'. - , issued 20 , such authority and permission is hereby granted
to the property owner to lawfully occupy or use said premises or building or part thereof listed under the
following New York State Classifications, Use: )2-3 16nif / , Construction: ,
for the following purposes: Val
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 been obtained from the Buildin nspector.
Acting Building Inspector,Village of Rye Brook: Date:
D �C ENE
FEB -8 2023 BUILD ENT For office use onl
�- PERMIT#
VILLAGE OF RYE BROOK VIL of R�'E OK ISSUED: —Jay Z j
BUILDING DEPARTMENT 38 KING STRE YE Book; v YoRlc 10573 DATE:
FEE: PAID
i
APPLICATION FOR CERTIFICATE OF OCCUPANCY,CERTIFICATE OF COMPLIANCE,
AND CERTIFICATION OF FINAL COSTS
i
TO BE SUBMITTED ONLY UPON COMPLETION OF ALL WORK AND PRIOR TO THE FINAL INSPECTION
ssssssssssssssassssasssssesuasssssassssaaaasaaaassrassssssasssasaaratassssssasssaassssssasasssssssaasisassusaaaasssssssssss
Address: 16 W man Street North
Occupancy/Use: 1-Family Parcel ID#:141.35-1-4.6 Zone: R2-F
I
owner: Louis Larizza & Santa Larizza Address: 25 South Regent Street, Port Chester
P.E./R.A.or Conti-actor: Pawlinq Holdings Address: 25 South Regent Street, Port Chester
Person in responsible charge: Louis Larizza Address: 25 South Regent Street, Port Chester
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:
Louis Larizza being duly swom,deposes and says that he/she resides at 25 South Regent Street
(Print Name of Applicant) (No.and Street)
in Port Chester ,in the County of Westchester in the State off_,that
(Cityrrown/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:$ 25,000.00
for the construction or alteration of. Interior Kitchen Renovation
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-IO.A.of the Code of the Village of Rye Brook.
Sworn to before me this_,`' J Sworn to before me this
Isignature
,20g1j- day of ,204L _
L
;arizza
ne SignatureofA ica�\ . �t
Print Name of Property Owner Print Name of App cant
Notary Pt lic
Notary P tic O .VESPIA HOPE B.VESPIA
Notary Public,State of New York Notary Public,State of New York S/I2J_MI
No. 01 VE5hester No.01 VE5084028
Qualified In Westchester Count J Qualified in Westchester County J
Commission Expires August 25,20z Commission Expires August 26,20jW
�yE BRC��.
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 ryebrook.org
- - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - -
ADDRESS : 0 DATE: 3
PERMIT# ` ISSUED:—4 `a$CT: I?~tILOCK: LOT: 1
LOCATION: '� ` �� (�"` " '�`�bCCUPANC
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❑ Violation Noted THE WORK IS.../pIASSED ❑ 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
❑ CR6SS CONNECTION
INAL
OTHER
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• BUILD��ISEp E4RnvARTMENT R
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IF ID
VILLAGE OF RYE BROOK MAY 2 5 2021
93 8 KING STREET RYE BRoo*,NY 10573
(914)939r _(91�4)939-5801 VILLAGE OF RYE BROOK
BUILDING DEPARTMENT
ysyfi o .or
ELECTRICAL PERMIT APPLICATION
Westchester County Master Electricians License Required
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FOR OFFICE USE ONLY BP#• tic �tL' EP#: C;)
Approval Date. MAY 2 5�&V Permit Fee: $
Approval Signature: - I Other:
Disapproved:
(fees are non-refundable)
Application dated, al is hereby made to the Building Inspector of the Village of Rye Brook NY, for the issuance of
7
a Permit to install an or reAlove 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: W M c� S'F N . SBL: `'`\ .3�, zone:1
2.Property Owner: l--d y 1 S L--cL-c C^-- Address:
Phone#:c1 k N 3q 9'eo Cell#: email:
3.Master Electrician: ", c,w13 (7u r\ e,Z Address: 3_� U ►-1\V CX S
Lic.#: Phone#: Gy) �G1 S bell#: email:C,e c_ e �-e-t- ( L (Go1�[ 4A,
v •C O (�
Company Name: e-C e 1 e- c } '( t C_ Address:
4.Proposed Electrical Work/Fixture Count: 2- 1 5
STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as:
t J Q_X CJ 6 O n 2; being duly swom,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 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 of 20
Signature of Property Owner S* ature of Appli t
, 30 opc 7� ,yttz_
Print Name of Property Owner Print Name of Applicant
Notary Public Notary Public
3/21/19
P6
Westchester Rockland Electrical Inspection Services, Inc. t Phone• 47-3595
DO NOT WRITE HERE-FOR OFFICE USE ONLY 43 North Lawn Avenue 14 47-3596
•
Elmsford, NY 10523 Tw � -,low.SUXDIAG PERMIT No.
TEMP k DATE; y
r�
CITY OR VILLAGE ZIP CODE TOWNSHIP CQUNTy
J ;C -1/
STREET AND NO.OR ROAD POLE NUMBER
BETWEEN WHAT TWO CROSS STREETS IS PREMISES LOCATED? SECTION BLOCK
OCCUPANT'S NAME BUILDING OCCUPANTV)
OWNER'S NAME AND ADDRE�
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.
3'�FL. VILLAGEOF RY BROO
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❑ ADDITIONAL❑ EXPOSED❑ CONCEALED❑ MUST ENTER APPLICANTS
IDENTIFICATION NUMBER
SERVICE ENTERS BUILDING OVERHEAD❑ UNDERGROUND C
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
sec_ .Q�eCA c �c ``� 1 �-'� I L X
STREET ADDRESS ` �' TELEPHONE NO. � ' 'A
�C\A-X)QJt 1 y
CRY OR POST OFFICE 1 ;0P LICENSE NO.WHEN APPLICABLE I
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BUIL yE Eu� MENT FEB - 8 2023
VIL E OF RYE OK VILLAGE OF RYE BROOK
938KIN I.`rRYi% ,NY 10573 ' BUILDING DEPARTMENT
(914)9 939-5801
oriz
PLUMBING PERMIT`APPLICATION
FOR OFFICE USE ONLY BP#: C� I- O e c4- PP#:
Approval Date: Permit Fee: $ / 6
Approval Signature: Other:
Disapproved:
(fees are non-refundable)
********************p********************* ********************************************************
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 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 1Local Codes.
1.Address: 16 Wyman Street Al SBL: PA 35-1— 7� (O Zone:/Q)—F
2.Proposed Work: One kitchen sink ,bathroom vanity
3.Property Owner: ) n�►S (.-Gt.f�Z G` Address: 16 Wyman Street
Phone#: q l 3 9(y%C(0 Cell#: email: LOO Laz_7_6d o_m (• Con
4.Master Plumber. Ken McCabe Address: P.O. Box 650 Briarcliff NY 10510
Lic.#: 983 Phone#: Cell#: 914-804-5412 email:
Company Name: VFR CONTRACTING Address: P.O.BOX 650 BRIARCLIFF NY 10510
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 st Floor 2
2nd Floor
31 Floor
TFloor
511 Floor
Exterior
5.*List Other Equipment/Provide Details:
(Notarized Signatures Required Next 2 Pages)
3/21/19
BUILD MENT
VIL E OF RY OK FEB - 8 2023
938 KING ET RYE BR ,NY 10573
(914)9 9' 39-5801 VILLAGE OF RYE. BROOK
,I BUILDING DEPARTMENT
xx*xx�xx*xxxxxxxxxxxxxxxx>xxxx,�xxxxxxx�x�xx,�xxxx�xxxxxxxxx�F�xxxxx�xx�xxxx,�xx�xxx�����x,�,�xxx,��>��FFx�xx
AFFIDAVIT OF COMPLIANCE
VILLAGE CODE 4216 - 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: p �J
T, of a is Lc2Li�� , residing at, cQ5 S, F-eLl4�� ���w��� ►"l
(Print name) (Address%Nh re you lire) /1
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;
16 Wyman Street , 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.
O40"4,0L
'�P',O�'M
(Signann' fhol f 0%% (s))
- Lrij 1 -, L o=t i z
(Print\ame ol'Property ON%ner(s))
Sworn to befo e me this
day of , 20 qJ
(Notary ublic)
HOPE B VESPIA
Notary Public,State of New Yerk
No.OIVE5084028
Qualified in Westchester Coun
ICommission Expires August 25,2
3/21/19
i
STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as:
Ken McCabe ,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
Contractor 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 bef me this Sworn to bcfo me this
day of ,20_ L3 day o 20 �
Si rope Owner ignat e Sf A licant
T-1
J_cst;�js G.lt ZZ Ken McCabe
Print Name of Property Owner Print Name of Applicant
r 'Awo �7aj�',I
Notary Rblic 7
gotary hh,,&E B VESPIA
Notary Public,State of New York
HOPE B VESPIA No.OIVE5084028
Notary Public,State of New York Qualified in Westchester Count•/,__
No.0 i VE5084028 Commission Expires August 25,2�J
Th �a ;��&I' ' 5, 2 s completed in its entirety and must I� s)of
th tA�t roperty, 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-
srzvl9
Building Permit Check List&Zoning Analysis
Address: t to �J y,�a,N ST SBL: l �-�= l -4 , G
Zone:?2 ' F Use: II -1 Lo Cont.Type: Other. R-4 AL t
Submittal Date: LI 1 1 t{ l z Revision Submittal Dates:
Applicant: L A(L L 2-Z L.;,,-
Nature of Work I V_.ATt'tLt D t-t— 4 L t'CL"4�r� —T RAJ
Reviews:ZBA: APR 1 5 2021
PB: BOT: Other.
OK
( ( ) FEES:Filing. l S �� BP: "3 1 S. i���y C/O: Legalization: 3• o�o '�
( ) (%�P: 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 tamped: Sealed Copies: Electronic: Other.
( ( ) Licene: Workers Comp: ✓ Liability: -"' Comp.Waiver. Other.
( ) ( ) CODE 7S3#: Dated: N/A:
HIGH-VOLTAGE ELECTRICAL:Plans: Permit N/A: Other.
( ) ( ) LOW-VOLTAGE ELECTRICAL:Plan: Permit: N/A Other.
FIRE ALARM/SMOKE DETECTORS:Plan: Permit: H.W.I.C.:—Battery.—Other.
(Jf ( ) PLUMBING:Plans: Permit: Nat.Gas: LP Gas: N/A/: Other.
( ) ( ) FIRE SUPPRESSION:Plan: Permit: N/A: Other.
( ) ( ) H.V.A.C.: Plan: Permit: N/A Other.
( ) ( ) FUEL TANK:Plan: Permit: Fuel Type: Other.
( ) ( ) 2020 NY State ECCC: N/A: Other.
( ) ( ) Final Survey Final Topo: RA/PE Sign-off Letter. As-Built Plan: 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 EXIMNG PROPOSED NOTES Date• APR 1 5 1011
Circle:
Fromm
Front:
Front:
Sides:
fir.
Main Cov
Accs.Cov
Ft,H/Sb:
S .HS :
Tot imp:
EL Imp:
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Hcight/Stories:
notes:
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ACORO" 04 I13/2021 CERTIFICATE OF LIABILITY INSURANCE °ATEIM YI
I2021
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 endorsementis).
PRODUCER CONTACT ,Joseph E SaNatore.AAI
NAME
BNC Insurance Agency PHONE (914)937-1230 FAX (914)937-1124
IA'C.No.Ealt. _ -_ AlC'No
90 South Ridge Street E-MAIL Ialvatore@bncagency.com
ADDRESS
INSURER(S)AFFORDING COVERAGE NAIL t
Rve Brook NY 1 INSURER A: Evanston Insurance Company 35378
INSURED INSURER B NGM Insurance Company 14788
h�:,in;l -aargs LLC INSURER
25 S-:1 Reoent Shunt,RFP•R INSURER D:
INSURER E-.
Por,Chester NY 10573 INSURER F
COVERAGES CERTIFICATE NUMBER: CL20112599002 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
NTR TYPE OF INSURANCE POLICY NUMBER MM DD ICYYYYY MMIDDlYYYY LIMITS
X COMMERCIAL GENERAL UAMLITY EACH OCCURRENCE S 1'0w'000
DAMAGE TO HEN I LU
CLAIMS4.tADE ®OCCUR PREMISES s occunencel S 100•000
x Contractual Liability EXCLUDED
MED EXP IAnY one Person) f
A X $10,000 Ded-Per Dec Y MKLVIPBC001345 11/17/2020 11117/2021 PERSONAL 6 ADV INJURY S 1,000 000
GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2.000.000
JE LOC 2.000.000POLICY C
OTHER S
AUTOMOBILE LIABILITY COM NED SINGLE LIMIT S 1,000.000
a ac en
ANY AUTO BODILY INJURY IPr pwton) $
B OWNED SCHEDULED B1V40294 09/11/2020 09/11/2021 BODILY INJURY(Per student l S
AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTY DAMAGE f
AUTOS ONLY AUTOS ONLY Per acc
EPLUS f
UMBRELLA UAS OCCUR EACH OCCURRENCE S 5•000•000 ---�-
A EXCESS LIAB CLAIMS-MADE MKLVIEUL102614 11/17/2020 11/17/2021 AGGREGATE $ 5.000,000
DED RETENTION S S
WORKERS COMPENSATION PER OTH.
AND EMPLOYERS'UABIUTY YIN STATUTE ER
ANY PROPRIE TOR/PARTNERIEXECUTIVE
OFFICERMEMBER EXCLUDED, ❑ NIA N/A EL FACH ACCIDENT g
(Mandatory in NMI E.l. DISEASE-EA EMPLOYEE $
B yea.describe undw
DESCRIPTION OF OPERATIONS below El DISEASE-POLICY LIMIT S
L -1 --1— N/A
DESCRIPTION OF OPERATIONS i LOCATIONS I VEHICLES(ACORD 101.AddSwnal Remarks Schedule.may be attached if mon apace u rpuued)
The Certificate Holder is included as an additional insured when required under written Contract or Agreement
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
AUTHORIZED REPRESENTATIVE
NY 10573
01998-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016,031 The ACORD name and logo are registered marks of ACORD
/vm:�N
NYSIF
New York State Insurance Fund 199 CHURCH STREET,NEW YORK,N.Y. 10007-1100
1 nysif.com
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
n n A A A A 451481271
LEVITT-FUIRST ASSOCIATES LTD
520 WHITE PLAINS ROAD,2ND FL
TARRYTOWN NY 10591
SCAN TO VALIDATE
AND SUBSCRIBE
POLICYHOLDER CERTIFICATE HOLDER
PAWLING HOLDINGS LLC VILLAGE OF RYE BROOK
25 South Regent Street(REAR) 938 KINGS STREET
PORT CHESTER NY 10573 RYE BROOK NY 10573
POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE
G2146 860-8 436679 06/29/2020 TO 06/29/2021 4/13/2021
THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE
FUND UNDER POLICY NO. 2146 860-8, 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:/IWWW.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 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: 947891683
U-26.3