HomeMy WebLinkAboutBP21-135PERMIT #
SECTION
TYPE OF WORK
JOB LOCATION
OWNER
CONTRACTOR_
EST. COST +�
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TCO #
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DATE: C� �3 EXP:,
BLOCK C=;- LOT,
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FEE
FEE DATE
INSPECTION RECORD
I DATE I NSP
FOOTI N G
FOUNDATION
FRAMING
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INSULATION ,�,/ /n/P
OR
PLUMBING // J
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SPRINKLER #
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AS BUILT n
FINAL
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VILLAGE OF RYE BROOK
WESTCHESTER COUNTY, NEW YORK
NO: 21-204
Cextifirate of (Occupaucp
This is to certify that 0 /�o D eT C.c
of, / 1 Y i l 13 Yo C—) k= 0 /\ T having duly filed an application on
De ! !be r /+20�_requesting a Certificate of Occupancy for the premises known as,
Q AyonCirCIC , Rye Brook,NY, located in a Zoning
District and shown on the most current Tax Map as Section: )S5.7 Block: Q Lot: ,
and having fully complied with the requirements of the Building Code and the Zoning Ordinance under Building
Permit No.a I — ` , issued (a 1.3 20 c:-� ) , 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: _3 I Joe, FOOL 1 / ' , for the following purposes:
I n +erlbY V-i when 1 - h IA pqrndes
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 shal ade,nor shall the building be moved from one location
to another until a permit to accomplish such change has been o ain from the uilding In ctor.
Assistant Building Inspector,Village of Rye Brook: Date: DEC 2 9 2021
DE `_� E � " For office use only.
i$UILDW TMENT PERMU#
DEC 17 2021 VILLAGE OF RYE BROOK ISSUED:
938 KING STREET,'RYE BROOK,,NFw YORK 10573 DATE: .-/7-a/
VILLAGE OF RYE BROOK (914)939-0669 FEE: cA //tom- PAJI(
BUILDING DEPARTMENT „*W,>I , »aa rg
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
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Address: I 'V on ?jrm K Yi� t oxY�3
Occupancy/Use: ! FAR Excel iD#: Z3,5—, 7 S of—6-0+ 8��V
-� Zone:/�/
Owner: CQ-r 61 u V) l�Jesu Address: �I I� � C1 r C 1 1 L-- 1� 16 S-7 ?
P.E./R.A. or Contractor: 7br Address:
Person in responsible charge: Address:
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 YY>K,COUNTY OF WESTCHESTER as: 1
O � WJ� being duly sworn,deposes and says that he/she resides at Ti Q b'Y CN X rd 6 #1b l V 57
(Prinf Name]offApplicant) T (No.and Street)
in 'R C,.4Q Piro 0k in the County of in the State of N ,that
(Cityrlowni 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:
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§250-10.A.1of the Code of the Village of Rye Brook.
Swom to before me this \ Sworn to before me this
day of �, 20 day of
Signature of Property OtyS' ture o Appli t
rfriW Name of Property bwner ame of Appikant
Notary Public SHARI MELILLO Notary Pubb%HARI MELILLO
Notary Public, State of New York Notary Public, State of New York
No. OtM. StCc'�033 No. 01L1cF16 ^03 8/12/2021
01 ivied in Westch:..ter County 0 ra9!fied in Westch.:ster County
Commission Expires January 29.20 Commission Expires January 29.20al
4 E BR k
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• 1982 BUILDING DEPARTMENT
❑BUILDING INSPECTOR
EarA, BUILDING INSPECTOR VILLAGE OF RYE BROOK
AlCODE ENFORCEMENT OFFICER 938 KING STREET • RYE BROOK,NY 10573
(914) 939-0668 FAx (914) 939-5801
www ryebrook.org
- - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - -
ADDRESS : DATE'
PERMIT# ISSUED: SECT: ��—�BLOCK: LOT: , Z�
LOCATION: f�1 � r ASV( t�"6CCUPANCY:
❑ VIOLATION NOTED THE WORK IS... s ACCEPTED 0 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
E BRC��.
cu �
BUILDING DEPARTMENT
❑BUILDING INSPECTOR
ASSISTANT BUILDING INSPECTOR VILLAGE OF RYE $ROOK
f]CODE ENFORCEMENT OFFICER 938 KING STREET • RYE BROOK,NY 10573
(914) 939-0668 FAX (914) 939-5801
www ryebrook.org
- - - - - - - - --- - - -- - - -- - INSPECTION REPORT - - - - -- - - - - - - -- - - - - - -
r 1
ADDRESS :- _ _DATE:
PERMIT# � 1 ISSUEDO'; SECT: BLOCK: LOT:
LOCATION: OCCUPANCY: 216
r
❑ VIOLATION NOTED THE WORK IS... ❑ ACCEPTED 0 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
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+ BUIL Dit MENT D
VIL E OF RYE OK
938 KrN EET RYE B o ,NY 10573 MAY 2 8 2021
(914)9r 0 939-5801 VILLAGE OF RYE
wy9i9o_cxk.org BROOK
BUILDING DEPARTMENT
ELECTRICAL PERMIT APPLICATION -
Westchester County Master Electricians License Required 1 G,
FOR OFFICE USE ONLY BP #: —1 EP#:
Approval Date: J U N - 1 2 ] Permit Fee: $
Approval Signature: Other:
Disapproved:
(fees are non-refundable)
Application dated, J C cw is hereby made to the Building Inspector of the Village of Rye Brook NY, for the issuance of
a Permit to install and/or remove electrical equipment, wiring, fixtures,or to perform other high or low voltage electrical work as per
the detailed statement described below. 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: 11 n G1 rk � TO SBL: 35•�r7 �o� ' �� t� Zone:—
r
2.Property Owner: Q_If O I l,ln bP- Z�jt Address: SORT, (AS 6Lk(j)V e
Phone#: !1 14 -SAS Lk - 01`�� Cell #: email: Cif 0\►Y)a e�'; J a Qi11«t 1 U
, s 7
3.Master Electrician: L0 V 15 m���� Address:
Lic.#: Phone#: 11`{ t( (-a-5J2�D Cell#: email:
Company Name: A qe-> f:xp 1A rva(1 Address: Ai Vh4--( Ave,. 1,kLj ?=:Q[kei k
4.Proposed Electrical Work/Fixture Count:
f f4r-
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.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 pie this
day of _ ,20 day of 20�_
Signature of Property Owner Signature&rAppliM5
Print Name of Property Owner P t Name of Applicant
Notary Public Notary PAM]MELILLO
Notary Public,State of New York
No. 01 ME6160063
Clualified in Westchester County
Commission Expires Jt3nus-P.a ?n9L3
3/21/19
Westchester Rockland Electrical Inspection Services, Inc. - Phone: 914-347-3595
DO NOT WRITE HERE-FOR OFFICE USE ONLY 43 North Lawn Avenue CEaPX -3
Elmsford, NY 10523 BUILDING PERMIT NO.
TEMP g JDA71
CITY OR VILLAGE _ ZIP CODE TOWNSHIP C04JNTY
5 u �tcr�eS�r
S7pND OR r POLE NUMBER
l` • ✓
BETWEEN WHAT TWO CROSS STREETS IS PREMISES LOCATED? SECTION
•� �ocK SO a
OCCUP S NAME — ''11 BUILDING OCCUPANCY
f Y ` V
OWNER'S NAME AND AdbREss OM TELEP ON
��E UM ER
-�(ji`}5
CURRENT SUPPLIED BY FROM THEIR OFFICE WORK TELEPHONE NUMBER
LIST BELOW ALL EQUIPMENT WHICH YOU INSTALLED
NUMBER OF OUTLETS NO.Or FIXTURES& MOTORS HEATERS OFFICE USE
LOCATION LAMP RECEPTACLES ONLY
SIDEWALL SWITCH INCADE FLUORE NO. H.P.EACH NO. WATTS EACH INSPECTION
OUTSIDE
BASEMENT _
r
I'FL
2"'FL-
3'•'FL VILLA 3E OF FjYE BROOK !
r: ---
REMARKS:LIST OTHER ELECTRICAL DEVIGES _ FORTH ABOVE:
VAre1 C \DT-CC, !
THIS APPLICATION IS INTENDED TO COVER THE ABOVE LISTED ITEMS TO BE INSPECTED.IF AT ANY TIME OF INSPECTION ADDITIONAL"EMS 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.VVREIS,INC.IS NOT LISTING,LABELING,UNDERWRITING OR CERTIFYING ANY EOUIPMENT,
MATERIALS OR DEVICES WHICH ARE PERFORMED BY OTHER CERTIFIED TESTING AGENCIES OR INSPECTION COMPANIES.THE APPLICANT,OWNER,OR AUTHORIZED AGENT AGREES TO
ALL THE ABOVE TERMS AND CONDITIONS AS SET FORTH FOR THE APPLICATION.
SIZE OF SERVICE FEEDERS
CHARACTER OF WORK NEW I.J ADDITIONAL L EXPOSED❑ CONCEALED❑ MUST ENTER APPLICANTS
IDENTIFICATION NUMBER
SERVICE ENTERS BUILDING OVERHEAD 1-1 UNDERGROUND
AVOID DELAYS SY:W FULL AND INFORMATION.ALL SPACE MUST BE FILLED IN OR APPLICATION MAY BE RETURNED..
,� �����E OF C�A�� DATE OF APPLICATION X IONAYU11Lr-OF APPLICANT
STREET ADDRESS TELEPHONE NO.
CRY OR POST OFTR¢fi ` 1 LICENSE NO.WHEN APPLICABLE
F oft
WESTCNESTER
ROCKLAND
ELECTRICAL
INSPECTION
WRE191SERVICES.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:
A Perfect/Goldman Electric Carolyn DeJesus
48 Potter Avenue
NY, New Rochelle 10801
Located at:91 Avon Circle Apt. D Rye Brook, NY 10573
Certificate Number: 1030914
Section: 135.75 Block:2 Lot: 50.2 Bill Permit Number: EP:21-129-BP:21-135
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 inion the premises at:
91 Avon Circle Apt. D Rye Brook,NY 10573
Basement list 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 09130/21
Name Type Quantity
Panel ------- 1
Clothes Dryer ------- 1
Clothes Washer ------- 1
Receptacle GFCI ------- 4
Receptacle Convenience ------- 2
Oven Gas or Electric ------- 1
Microwave ------- 1
Range Hood ------- 1
Dishwasher ------ 1
Switch Single Pole ------- 1
This Certificate has been approved by Westchester Rockland Electrical Inspection Services.
This certificate may not be altered in any way. ✓���i�` ` �
This certificate is valid for work performed before date of inspection only.
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BUIL I EpA MENT MAY 2 8 2021�
VIIL GE OF RYE R OK
938 KIN ET RYE BRoo>C,NY 10573 VILLAGE OF RYE BROOK
(914)9 6 ` A)J14)939-5801 BUILDING DEPARTMENT
or
MIT PLUMBING PER APPLICATION
FOR OFFICE USE ONLY BP#: Q/ °-I 35— PP#: c>—))^0
97
Approval Date: '�UN 1 2021 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 an 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: C_ -c- SBL Zone:
2.Prop 's d Wor :s
W CL L 0 u v_ t a� f
3.Property Owner: 0-'-C' 4' �Sy Address: CI C
Phone#:9 7— Q1L}_}1 Cell#: email: ' r A. Co
4.Master Plumber CD l�,[` A�'ddress: U t�r 1 ec o D
Lic.#: 51 � Phone#: �$g U H y 9 Cell#:9 ``�'D 71 go-7`t email:
Company Name: f. ✓-�C) Q Address: y
INDICATE FIXTURES&LINES TO BE INSTALLED AS PER THE FOLLOWING SCHEDULE: l O&O -7
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
2nd Floor I I
31d Floor J
4ie Floor
5a'Floor
Exterior
5.*List Other Equipment/Provide Details:
(Notarized Signatures Required Next 2 Pages)
I
3/21/19
STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as:
A QYO 7a7�-lJO I- ,being duty swom,deposes and states that he/she is the applicant above named,
(print name off 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
for the legal owner and is duly authorized to make and file this application.
(indicate architect,contractor,agent,attorney,etc.)
That all statements contained herein are true to the best of his/her knowledge and belief,and that any work performed,or use
conducted at the above captioned property will be in conformance with the details as set forth and contained in this application
and in any accompanying approved plans and specifications,as well as in accordance with the New York State Uniform Fire
Prevention&Building Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances and regulations.
Sworn to before me this Sworn to before me this
day of ,20 day of 4 20 c.)L
-zen�
Signature of Property Owner Signature of Applican
0
Print Name of Property Owner Print NqKe 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-
321/l9
STAT F NEW Yo r CO TY OF WESTCHESTER ) as:
being duly sworn,deposes and states that he/she is the applicant above named,
(print name of i i ual signing s the applicant)
and t that( he is the legal owner of the property to which this application pertains,or that(s)he is the
cs ( 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,ordinan d regulations.
Sworn to before me this Sworn before a this
day of 94 20. day of ,20
CI
Si ature of Prop&ty Owner Signature of A t
Wo Q-Sas
Print Name of P perry Owner Print Name of Applicant
Notary Pu Notary Public
GEIrNADIY M Ov
OF NEW YORK
NOTARYs�tio C o 01MA6(187608
in Queens County
Qualifi 20
Thi 1�1 18 le nt'irety and must include the notarized signature(s)of
the legal owher(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/l9
RDECENE
BUILDING` J1EtP�R'�MENT
VILa6E OF R 1toOK MAY 2 8 2021
938 KING�T'� FET RYE Blk alk,NY 10573
(914)934=060.>�(9I4�1`939-5801 VILLAGE OF RYE BROOK
w�M>V.i'ye yokhrg BUILDING DEPARTMENT
r c.
***WWWWWWWW****************************##W**#*###W#WWWWW****************************W******************
AFFIDAVIT OF COMPLIANCE
VILLAGE CODE 216 • STORM SEWERS AND SANITARY SEWERS
THIS AFFIDAVIT MUST BEAR THE NOTARIZED SIGNATURE OF THE LEGAL PROPERTY OWNER AND BE SUBMITTED ALONG
WITH ANY BUILDING OR PLUMING 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�l1TY OF WESTCHESTER ) as:-V7�3 - ��,n I n
, residing at, U Y ► �UC � I
(Vint name) I,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;
w
ql1 V M j �AL btkli n Rye Brook, NY.
,h 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.
AIA
15i, aturc of I'ro�crt5° hA ncr{.)1
0&ro�n baczdz�
Print vttmaofPropert Okvnctls))
Sworn to before me this
day of , 20
(Notary P
G NADIY AAATATOV
NOTARY BLIC,STATE OF NEIAI YO
gistration No.01 MA6087608
Qualified in Queens County
mmission Expires February 18,20
3/21/19
Building Permit Check List&Zoning Analysis y
Address: AV 0 N (2 C 1_F SBL
Zane — 1 Use: Const.Type: Other.
Submittal Date: S 'Z_77I Z Revisions Submittal Dates:
Applicant:
Nature of Work: I (L_ �t,k`Cr_qRS__S 0)A:r,R -S
Reviews:ZBAJ UN — 1 2021 PB: BOT: Other.
OK
{ ( ) ES:Filing, 7-�' BP: � � ' � C/O: Legalization:
( } ( 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 Staged Sealed Copies: Electronic Other.
( ) ('�L tense: Workers Comp: Liability: omp.Waiver. -7~ Other.
( ) ( ) 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: FLW.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: approvab notes: APPROVED
9011UIRED EXISTING OSED NOTES �
Aux REQ PROP �81w@' JUN 1 2
Cudc
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Front:
Front
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notes:
TIRSA Owner's Extended Protection Policy
♦5, A M k'C 1
4 FOR A ONE-TO-FOUR FAMILY RESIDENCE
FirstAmerican Title`
�440ISSUED BY
First American Title Insurance Company
■ POLICY NUMBER
Owner's Policy 5032936-0007511 e
OWNER'S COVERAGE STATEMENT
This Policy insures You against actual loss, including any costs, attorney's fees and expenses provided under this Policy,
resulting from the Covered Risks set forth below, if the Land is an improved residential lot on which there is located a one-
to-four family residence and each insured named in Schedule A is a Natural Person.
This Policy is not complete without Schedules A and B.
Your insurance is effective on the Policy Date. This Policy covers Your actual loss from any risk described under Covered
Risks if the event creating the risk exists on the Policy Date or, to the extent expressly stated, after the Policy Date.
Your insurance is limited by all of the following:
• The Policy Amount shown in Schedule A
• For Covered Risk 14, 15, 16 and 18, Your Deductible Amount and Our Maximum Dollar Limit of Liability shown in
Schedule A
• Exceptions in Schedule B
• Exclusions on page 3
• Conditions on page 3, 4 and 5
In Witness Whereof, First American Title Insurance Company has caused its corporate name to be hereunto affixed by its
authorized officers as of Date of Policy shown in Schedule A.
First American Title Insurance Company For Reference:
File#: 142060
Issued By:
Dennis J.Gilmore,President
- The Judicial Title Insurance Agency, LLC
800 Westchester Avenue
Rye Brook, NY 10573
Greg L.Smith,Secretary
(This Policy is valid only when Schedules A and B are attached) This jacket was created electronically and constitutes an original document
Form 5032936(4-8-18) Page 1 of 5 TIRSA Owner's Extended Protection Policy For A One-To-Four Family Residence(1-11-01)
New York
First American Title Insurance Company
TIRSA Owner's Extended Protection Policy
For A One-To-Four Family Residence
TABLE OF CONTENTS
Page
OWNER'S COVERAGE STATEMENT 1
COVERED RISKS 1
SCHEDULE A
Policy Number, Premium, Date and Time and Amount
Deductible Amounts and Maximum Dollar Limits of Liability
Street Address of the Land
1. Name of Insured
2. Interest in Land Covered
3. Description of the Land
SCHEDULE B—EXCEPTIONS
EXCLUSIONS 2
CONDITIONS
1. Definitions 2
2. Continuation of Coverage 2
3. How to Make a Claim 2
4. Our Choices When We Learn of a Claim 2
5. Handling a Claim or Legal Action 3
6. Limitation of Our Liability 3
7. Our Duty to Defend Against Legal Actions 3
S. Transfer of Your Rights to Us 3
9. Entire Contract 3
10. Increased Policy Amount 3
11. Severability 3
12. Arbitration 3
First American Title Insurance Company
TIRSA Owner's Extended Protection Policy
For A One-To-Four Family Residence
OWNER'S INFORMATION SHEET
It applies only to a one-to-four family residence and only if each insured name in
Schedule A is a Natural Person. If the Land described in Schedule A of the Policy is not
an improved residential lot on which there is located a one-to-four family residence, or if
each insured named in the Schedule A is not a Natural Person, contact Us immediately.
The Policy insures You against actual loss resulting from certain Covered Risks. These
Covered Risks are listed on page I of the Policy. The Policy is limited by:
Provisions of Schedule A
Exceptions in Schedule B
Our Duty to Defend Against Legal Actions on page 1
Exclusions on page 2
Conditions on pages 2 and 3
You should keep the Policy even if You transfer Your Title to the Land.
If you want to make a claim, see paragraph 3 under Conditions on page 2.
You do not owe any more premiums for the Policy.
This sheet is not Your Insurance Policy. It is only a brief outline of some of the
important Policy features. The Policy explains in detail Your rights and obligations and
Our rights and obligations. Since the Policy—and not this sheet—is the legal document.
YOU SHOULD READ THE POLICY VERY CAREFULLY
If You have any question about Your Policy, contact:
The Judicial Title Insurance Agency LLC
(914) 381-6700
D
MAY 2 7 2021
First American Title Insurance Company VILLAGE OF RYE BROOK
BUILDING DEPARTMENT
Schedule A — Owner's Extended Protection Policy
Policy Number: 50329360007511Title Number: 142060FA-W
Policy Amount: $230,000.00 Police Date: May 12, 2021
Deductible Amounts and Maximum Dollar Limits of Liability
For Covered Risk 14, 15, 16, and 18
Your Deductible Our Maximum Dollar
Amount Limit of Liability
Covered Risk 14 (Subdivision Law Violation): $2,000.00 $10,000.00
Covered Risk 15 (Building Permit): $4,000.00 $25,000.00
Covered Risk 16 (Zoning): $4,000.00 $25,000.00
Covered Risk 18 (Encroachment of Boundary
Walls or Fences): $1,500.00 $5,000.00
Street Address of the Land:
Rye Ridge Condominium
91 Avon Circle, Unit No. D
Rye Brook, New York
1. Name of Insured: CAROLYN DEJESUS
2. Your interest in the Land covered by this Policy is: Fee Simple
3. The Land referred to in this Policy is described as follows:
See Schedule A attached hereto
Countersigned:
Authorized Officer or Age
914-381-6700
THE JUDICIAL TITLE INSURANCE AGENCY LLC
First American Title Insurance Company
Schedule B— Owner's Policy
Exceptions from Coverage (continued)
Policy Number: 50329360007511
File Number: 142060FA-W
7. If the premises are serviced by a water meter, a final meter reading must be obtained and a bill
for meter charges submitted at the time of closing. If a bill is not submitted at closing, policy
excepts all meter charges from the last date of reading.
NOTE: Closers are NOT permitted to OMIT this exception for Owners Policy unless an
actual bill is presented at closing.
8. RESTORED TAXES - PURCHASER: As the premises herein is benefited by a tax exemption,
policy excepts the lien which may attach by reason of any restoration of real property taxes after
the transfer of title by the owner entitled to the tax exemption.
First American Title Insurance Company
Schedule B— Owner's Policy
Exceptions from Coverage
Policy Number: 50329360007511
File Number: 142060FA-W
This policy does not insure against loss or damage (and the Company will not pay costs,
attorneys' fees or expenses)which arise by reason of:
1. Rights of tenants or persons in possession, if any.
2. The exact courses, distances, dimensions and location of the premises described in Schedule A
cannot be insured in the absence of a satisfactory survey guaranteed to this Company.
3. Policy excepts any states of facts which an accurate survey of the unit would show, but policy
insures that any encroachments by the insured unit on any adjoining unit, or on common areas,
may remain as long as it shall stand.
4. Policy excepts covenants, conditions, easements, leases, agreements of record, etc., set forth in
schedule herein.
Sewer Easement in Liber 5312 cp. 366.
Rules and Regulations Rye Ridge Condominium in Control No. 522843569.
Declaration of Condominium and By Laws recorded in Liber 7232 cp. 198, as amended in Liber
7950 cp. 15, but policy insures against loss or damage occasioned by the subject premises not
being a part of a Condominium validly created pursuant to Article 9-B of the Real Property Laws,
as amended.
5. Mortgage made by CAROLYN DEJESUS to FAMILY FIRST FUNDING LLC ISAOA/ATIMA
its successors and/or assigns in the amount of $218,500.00 dated May 12, 2021 and to be
recorded
6. This policy does not insure against charges or fees levied by the local governing municipality, its
various departments and/or agencies unless said charges are listed as liens within the tax
department or in the county clerk's office prior to closing.
THE JUDICIAL TITLE INSURANCE AGENCY LLC
Title Number: 142060FA-W
SCHEDULEA
THE Unit (hereinafter referred to as "Unit") known as Unit No. 91 B-1 D, Village of Rye
Brook, Town of Rye, Westchester County, New York and also designated and described
as Unit No. 91 B-1 D, in the Declaration establishing a plan for Condominium ownership
of the land and buildings comprising the Rye Ridge Condominium (hereinafter called the
"Property"), made by the Sponsor under Article 9B of the New York Real Property Law,
dated November 8, 1974 and recorded in the Office of the County Clerk of Westchester
County on November 8, 1974, in Liber 7232 of Conveyances at page 198 (hereinafter
called the "Declaration"), which Unit is also designated as Tax Lot No. 91 B-1 D on the
Floor Pans of the Buildings, certified by Bernard Arnold on October 10, 1974 and filed
simultaneously with said Declaration in the Office of the Clerk of Westchester County, as
Map No. 18388 (hereinafter called the "Unit").
TOGETHER with an undivided 0.5219% interest in the Common Elements of the
Property described in said Declaration (hereinafter called the "Common Elements").
THE Land upon which the building containing the Unit is more fully described in said
Declaration of Condominium.
The policy to be issued under this report will insure the title to such buildings and
FOR improvements erected on the premises which by law constitute real property.
CONVEYANCING
ONLY TOGETHER with all the right, title and interest of the party in the first part, or, in and
to the land lying in the street in front of and adjoining said premises.
Pagc 1 of i
THE JUDICIAL TITLE INSURANCE AGENCY LLC
Title Number: 142060FA-W
SCHEDULE OF COVENANTS, CONDITIONS, EASEMENTS,LEASES,
AGREEMENTS OF RECORD, ETC.
Sewer Easement in Liber 5312 ep. 366.
Rules and Regulations Rye Ridge Condominium in Control No. 522843569.
Furnished upon request.
Declaration of Condominium and By Laws recorded in Liber 7232 cp. 198, as amended
in Liber 7950 cp. 15, but policy insures against loss or damage occasioned by the subject
premises not being a part of a Condominium validly created pursuant to Article 9-B of
the Real Property Laws, as amended.
See copies attached.
Page 1 of 1
First American Title Insurance Company
STANDARD NEW YORK ENDORSEMENT
(OWNER'S POLICY)
Title No. 142060
Attached to and made a part of Policy No. 50329360007511
1. The following is added as a Covered Risk:
11. Any statutory lien arising under Article 2 of the New York Lien Law for
services, labor or materials furnished prior to the date hereof, and which has now
gained or which may hereafter gain priority over the estate or interest of the
insured as shown in Schedule A of this policy.
2. Exclusion Number 5 is deleted, and the following is substituted:
5. Any lien on the Title for real estate taxes, assessments, water charges or sewer
rents imposed by governmental authority and created or attaching between Date of
Policy and the date of recording of the deed or other instrument of transfer in the
Public Records that vests Title as Shown in Schedule A.
The endorsement is issued as part of the policy. Except as it expressly states, it does not (i)
modify any of the terms and provisions of the policy, (ii) modify any prior endorsements, (iii)
extend the Date of Policy, or(iv) increase the Amount of Insurance. To the extent a provision of
the policy or a previous endorsement is inconsistent with an express provision of this
endorsement, this endorsement controls. Otherwise, this endorsement is subject to all of the
terms and provisions of the policy and of any prior endorsements.
Dated: 05/12/2021
Countersigned
BY:
Zuse
Signato
Standard New York Endorsement dtk LTA Owner's Policy(6117106)
First American Title Insurance Company
POLICYA UTHENTICA TION ENDORSEMENT
Title No. 142060
Attached to and made part of Policy Number: 50329360007511
When the policy is issued by the Company with a policy number and Date of Policy, the Company
will not deny liability under the policy or any endorsements issued with the policy solely on the
grounds that the policy or endorsements were issued electronically or lack signatures in
accordance with the Conditions.
This endorsement is issued as part of the policy. Except as it expressly states, it does not (i)
modify any of the terms and provisions of the policy, (ii) modify any prior endorsements, (iii)
extend the Date of Policy, or (iv) increase the Amount of Insurance. To the extent a provision of
the policy or a previous endorsement is inconsistent with an express provision of this
endorsement, this endorsement controls. Otherwise, this endorsement is subject to all of the terms
and provisions of the policy and of any prior endorsements.
Date: 05/12/2021
Policy Authentication Endorsement(612412016)
First American Title Insurance Company
MARKET VALUE POLICY RIDER
(TIRSA OWNER'S EXTENDED PROTECTION POLICY ONLY)
Title No. 142060
Attached to and made part of Policy Number 50329360007511
Owner's Statement of Coverage:
In consideration of the payment of the additional premium for the issuance of this Rider to the TIRSA Owner's Extended
Protection Policy, the Policy insures against loss or damage not exceeding the market value of the premises at the time of loss,
in accordance with the Exclusions and Conditions of the Policy not inconsistent with the provisions of this Rider, and subject
to the matters excepted from coverage in Schedule B.
DEFINITIONS:
(a) Time of loss shall be such date as the insured shall have actual knowledge offacts giving rise to a claim under the
Policy.
(b) A homeowner is a natural person,fee owner and resident of real property used predominantly for residential
purposes and containing no more than 4 dwelling units, or a residential condominium unit. The benefits of this
Rider shall be available only to the named insuredprovided the named insured is a homeowner as defined herein
at the date of the issuance of this Rider and at the date any claim under this Rider is made.
(c) Market value at time of loss shall be such value of the insured premises as is determined by three arbitrators or
any two of them, one of whom should be chosen by the insured and one by the Company, and the two so chosen
selecting the third arbitrator. Such value shall exclude the market value of any improvements made to the
premises subsequent to the date of the Policy.
CONDITIONS:
(a) Paragraph 10 of the Conditions of the Policy is hereby deleted.
In the event that a loss occurs after the insured makes an improvement to the insured premises subsequent to the
date of this Rider the valuation ofsuch loss shall be determined in relationship to the market value of the
premises at the time ofsuch loss, minus the market value ofsuch improvements made to the insured premises
subsequent to the date of this Rider.
(b) Notwithstanding anything herein to the contrary, in the event of a loss,partial or total, the insured shall have the
option to elect to value such loss under the terms of this Rider or under the terms and amount of the Policy.
(c) This Endorsement does not increase or decrease any amount shown under "Your Deductible Amount"set forth in
Schedule A of the Policy and does not increase or decrease any amount shown under "Our Maximum Dollar
Limit of Liability"set forth in Schedule A of the Policy.
This endorsement is made apart of the Policy and is subject to all of the terms andprovisions thereof and of any other
endorsements thereto. Except to the extent expressly stated, it neither modifies any of the terms and provisions of the Policy and
any other endorsements,nor does it extend the effective date of the Policy and any other endorsements, nor does it increase the
face amount thereof.
Dated: 0511212021
Countersigned
BY:
Authorizedsigneftory
TIRSA MARKET VALUE POLICY RIDER (04124101)
COVERED RISKS
The Covered Risks are: Date, because they violate an existing zoning law or zoning
1. Someone else owns an interest in Your Title. regulation. The amount of Your insurance for this Covered Risk
2. Someone else has rights affecting Your Title arising out of leases, is subject to Your Deductible Amount and Our Maximum Dollar
contracts,or options. Limit of Liability shown in Schedule A.
3. Someone else claims to have rights affecting Your Title arising 17. You cannot use the Land because use as a single-family
out of forgery or impersonation. residence violates a zoning law or zoning regulation existing at
4. Someone else has an easement on the Land. Policy Date.
5. Someone else has a right to limit Your use of the Land. 18. You are forced to remove Your structures,or any part of them,as
6. Your Title is defective. existing at Policy Date, because they encroach onto Your
7. Any of Covered Risks 1 through 6 occurring after the Policy Date. neighbor's land. If the encroaching structures are boundary walls
8. Someone else has a lien on Your Title, including a: or fences, the amount of Your insurance for this Covered Risk is
a: Mortgage; subject to Your Deductible Amount and Our Maximum Dollar
b: judgment,state or federal tax lien, or special assessment; Limit of Liability shown in Schedule A.
c: charge by a homeowner's or condominium association;or 19. Someone else has a legal right to, and does, refuse to perform a
d: lien, occurring before or after the Policy Date, for labor and contract to purchase the Land, lease it or make a Mortgage loan
material furnished before the Policy Date. on it because Your neighbor's structures, or any part of them, as
9. Someone else has an encumbrance on Your Title. existing at Policy Date,encroach onto the Land.
10. Someone else claims to have rights affecting Your Title arising 20. You are forced to remove Your existing structures because they
out of fraud,duress,incompetency or incapacity, encroach onto an easement or over a building set-back line, even
11. You do not have both actual vehicular and pedestrian access to if the easement or building set-back line is excepted in Schedule
and from the Land,other than vehicular access to a condominium B, provided that such encroachment is not excepted in Schedule
unit,based upon a legal right. B.
12. You are forced to correct or remove a violation existing at Policy 21. Your existing structures (or a replacement or modification made
Date of any covenant, condition or restriction affecting the Land, to them after the Policy Date), or any part of them, other than
even if the covenant, condition or restriction is excepted in boundary walls or fences, are damaged because of the future
Schedule B, provided that such violation of the covenant, exercise of a right to use the surface of the Land for the
condition or restriction is not excepted in Schedule B. extraction or development of minerals, water or any other
13. Your Title is lost or taken because of a violation of any covenant, substance, unless those rights are excepted or reserved from the
condition or restriction, which occurred before You acquired Your description of the Land or excepted in Schedule B.
Title, even if the covenant, condition or restriction is excepted in 22. Someone else tries to enforce a discriminatory covenant,
Schedule B, provided that such violation of the covenant, condition or restriction that they claim affects Your Title which is
condition or restriction is not excepted in Schedule B. based upon race,color, religion, sex, handicap, familial status, or
14. Because of a violation of a subdivision law or regulation existing national origin.
at Policy Date affecting the Land: 23. A taxing authority assesses supplemental real estate taxes not
a. You are unable to obtain a building permit; previously assessed against the Land for any period before the
b. You are forced to correct or remove the violation;or Policy Date because of construction or a change of ownership or
c. Someone else has a legal right to, and does, refuse to use that occurred before the Policy Date.
perform a contract to purchase the Land, lease it or make a 24. Your neighbor builds any structures after the Policy Date, other
Mortgage loan on it, than boundary walls or fences,which encroach onto the Land.
The amount of Your insurance for this Covered Risk is subject to 25, Your Title is unmarketable, which allows someone else to refuse
Your Deductible Amount and Our Maximum Dollar Limit of to perform a contract to purchase the Land, lease it or make a
Liability shown in Schedule A. Mortgage loan on it.
15. The cost of the forced removal of Your structures, or any part of 26. A document upon which Your Title is based is invalid because it
them, other than boundary walls or fences, as existing at Policy was not properly signed, sealed, acknowledged, delivered or
Date, because any portion was built without obtaining a building recorded,
permit from the proper government office. The amount of Your 27. The residence with the address shown in Schedule A is not
insurance for this Covered Risk is subject to Your Deductible located on the Land at the Policy Date.
Amount and Our Maximum Dollar Limit of Liability shown in 28. The survey map, if any, referred to in Schedule B of this Policy
Schedule A. does not show the correct location of the Land according to the
16. The cost of the forced removal of Your structures, or any part of Public Records.
them, other than boundary walls or fences, as existing at Policy
Form 5032936(4-8-18) Page 2 of 5 TIRSA Owner's Extended Protection Policy For A One-To-Four Family Residence(1-11-01)
New York
• EXCLUSIONS
In addition to the Exceptions in Schedule B, You are not insured 4. Risks:
against loss,costs,attorney's fees,and expenses resulting from: a. that are created, allowed, or agreed to by You, whether or
1. Governmental police power, and the existence or violation of any not they appear in the Public Records;
law or government regulation. This includes ordinances, laws b. that are Known to You at the Policy Date, but not to Us,
and regulations concerning: unless they appear in the Public Records at the Policy Date;
a. building c. that result in no loss to You;or
b. zoning d. that first occur after the Policy Date—this does not limit the
c. land use coverage described in Covered Risk 7, 8.d, 21, 22, 23, or
d. improvements on the Land 24.
e. land subdivision 5. Failure to pay value for Your Title.
f. environmental protection 6. Lack of a right:
This Exclusion does not apply to violations or the enforcement of a. to any Land outside the area specifically described and
these matters if notice of the violation or enforcement appears in referred to in paragraph 3 of Schedule A;and
the Public Records at the Policy Date. b. in streets,alleys,or waterways that touch the Land.
This Exclusion does not limit the coverage described in Covered This Exclusion does not limit the coverage described in Covered
Risk 14, 15, 16, 17 or 23. Risk 11 or 18.
2. The failure of Your existing structures, or any part of them, to be 7. Any claim which arises out of the transaction vesting in Your Title
constructed in accordance with applicable building codes. This by reason of the operation of federal bankruptcy, state
Exclusion does not apply to violations of building codes if notice insolvency,or similar creditors'rights law,that is based upon:
of the violation appears in the Public Records at the Policy Date. a. the transaction creating Your Title being deemed a
3. The right to take the Land by condemning it, unless: fraudulent conveyance or a fraudulent transfer;or
a. a notice of exercising the right appears in the Public b. the transaction creating Your Title being deemed a
Records at the Policy Date preferential transfer except where the preferential transfer
b. the taking happened before the Policy Date and is binding results from the failure:
on You if You bought the Land without Knowing of the i. to timely record the deed to You;or
taking. ii, of the recording of the deed to You to be notice to a
purchaser for value or a judgment or lien creditor.
CONDITIONS
1, DEFINITIONS: Trust — a living trust established by a human being for estate
Easement — the right of someone else to use the Land for a planning.
special purpose. We/Our/US—First American Title Insurance Company.
Known—things about which You have actual knowledge, The YouNour — the insured named in Schedule A and also those
words "Know" and "Knowing" have the same meaning as identified in paragraph 2.b.of these Conditions.
Known. 2. CONTINUATION OF COVERAGE:
Land — the land or condominium unit, and its interest in the a. This Policy protects You as long as You own Your Title or
common elements, described in paragraph 3 of Schedule A and own a mortgage from anyone who buys Your Land or are
any improvements on the land which are real property. liable for any title warranties You make. You cannot assign
Mortgage — a mortgage, deed of trust, trust deed or other this Policy to anyone else.
security instrument. b. This Policy also insures:
Natural Person — a human being, not a commercial or legal i. anyone who inherits Your Title because of Your death;
organization or entity. Natural Person includes a trustee of a ii. Your spouse who receives Your Title because of
Trust even if the trustee is not a human being. dissolution of Your marriage;
Policy Date—the date shown in Schedule A. If the recording iii. the trustee or successor trustee of a Trust to whom
date of the instruments creating the insured interest is later than You transfer Your Title after the Policy Date;or
the Policy Date, this policy shall also cover intervening liens or iv. the beneficiaries of Your Trust upon Your death.
encumbrances, except real estate taxes, assessments, water c. We may assert against the insureds identified in paragraph
charges and sewer rents. 2.b. any rights and defenses that We have against any
Public Records — records that give constructive notice of previous insured under this Policy.
matters affecting Your Title, according to New York State law. 3. HOW TO MAKE A CLAIM
With respect to Section 1.f. of the Exclusions, "public records" a. Prompt Notice Of Your Claim
shall also include environmental protection liens filed in the i. As soon as You Know, or could have known, of
records of the clerk of the United States district court for the anything that might be covered by this Policy, You
district in which the Land is located. must notify Us promptly in writing.
Title — the ownership of the interest in the Land, as shown in ii. Send Your notice to First American Title Insurance
Schedule A. Company,Attention: Claims National Intake Center,
1 First American Way,Santa Ana,California 92707.
Form 5032936(4-8-18) Page 3 of 5 TIRSA Owner's Extended Protection Policy For One-To-Four Family Residence(1-11-01)
New York
• CONDITIONS(Continued)
Please include the Title number and the Policy b. If You fail or refuse to cooperate with Us, Your coverage
number shown in Schedule A and the county where will be reduced or ended, but only to the extent Your failure
the Land is located. Please enclose a copy of Your or refusal affects Our ability to resolve the claim or defend
Policy,if available. You.
iii. If You do not give Us prompt notice, Your coverage c. We are required to repay You only for those settlement
will be reduced or ended, but only to the extent Your costs, attorneys' fees and expenses that We approve in
failure affects Our ability to resolve the claim or defend advance.
You. d. We have the right to choose the attorney when We bring or
b. Proof Of Your Loss defend a legal action on Your behalf. We can appeal any
I. We may require You to give Us a written statement decision to the highest level. We do not have to pay Your
signed by You describing Your loss which includes: claim until the legal action is finally decided.
(a) the basis of Your claim; e. Whether or not We agree there is coverage, We can bring
(b) the Covered Risks which resulted in Your loss; or defend a legal action, or take other appropriate action
(c) the dollar amount of Your loss;and under this Policy. By doing so, We do not give up any
(d) the method You used to compute the amount of rights.
Your loss. 6. LIMITATION OF OUR LIABILITY
ii. We may require You to make available to Us records, a. After subtracting Your Deductible Amount if it applies, We
checks,letters,contracts, insurance policies and other will pay no more than the least of:
papers which relate to Your claim. We may make i. Your actual loss;
copies of these papers. ii. Our Maximum Dollar Limit of Liability then in force for
iii. We may require You to answer questions about Your the particular Covered Risk, for claims covered only
claim under oath. under Covered Risk 14, 15, 16 or 18;or
iv. If You fail or refuse to give Us a statement of loss, iii. the Policy Amount then in force.
answer Our questions under oath, or make available b. i. If We remove the cause of the claim with reasonable
to Us the papers We request, Your coverage will be diligence after receiving notice of it, all Our obligations
reduced or ended, but only to the extent Your failure for the claim end, including any obligation for loss You
or refusal affects Our ability to resolve the claim or had while We were removing the cause of the claim.
defend You. ii. Regardless of 6.b. (i) above, if You cannot use the
4. OUR CHOICES WHEN WE LEARN OF A CLAIM Land because of a claim covered by this Policy:
a. After We receive Your notice, or otherwise learn, of a claim (a) You may rent a reasonably equivalent substitute
that is covered by this Policy, Our choices include one or residence and We will repay You for the actual
more the following: rent You pay, until the earlier of:
i. Pay the claim. (1) the cause of the claim is removed;or
ii. Negotiate a settlement. (ii) We pay You the amount required by this
iii. Bring or defend a legal action related to the claim. Policy. If Your claim is covered only under
iv. Pay You the amount required by this Policy. Covered Risk 14, 15, 16 or 18,that payment
v. End the coverage of this Policy for the claim by paying Is the amount of Your insurance then in
You Your actual loss resulting from the Covered Risk, force for the particular Covered Risk.
and those costs, altorney's fees and expenses (b) We will pay reasonable costs You pay to relocate
incurred up to that time which We are obligated to any personal property You have the right to
pay. remove from the Land, including transportation of
vi. End the coverage described in Covered Risk 14, 15, that personal property for up to twenty-five (25)
16 or 18 by paying You the amount of Your insurance miles from the Land,and repair of any damage to
then in force for the particular Covered Risk, and that personal property because of the relocation.
those costs, attorney's fees and expenses incurred up The amount We will pay You under this
to that time which We are obligated to pay. paragraph is limited to the value of the personal
vii. End all coverage of this Policy by paying You the property before You relocate it.
Policy Amount then in force and all those costs, c. All payments We make under this Policy reduce the Policy
attorney's fees and expenses incurred up to that time Amount, except for costs, attorney's fees and expenses.
which We are obligated to pay. All payments we make for claims which are covered only
viii. Take other appropriate action. under Covered Risk 14, 15, 16 or 18 also reduce Our
b. When We choose the options in paragraphs 4.a. (v), (vi)or Maximum Dollar Limit of Liability for the particular Covered
(vii), all Our obligations for the claim end, including Our Risk,except for costs,attorney's fees and expenses.
obligation to defend, or continue to defend, any legal d. If We issue, or have issued, a Policy to the owner of a
action. Mortgage on Your Title and We have not given You any
c. Even if We do not think that the Policy covers the claim, coverage against the Mortgage,then:
We may choose one or more of the options above. By i. We have the right to pay any amount due You under
doing so,We do not give up any rights. this Policy to the owner of the Mortgage to reduce the
5. HANDLING A CLAIM OR LEGAL ACTION amount of the Mortgage, and any amount paid shall
a. You must cooperate with Us in handling any claim or legal be treated as a payment to You under this Policy,
action and give Us all relevant information. including under paragraph 4.a.of these Conditions;
Form 5032936(4-8-18) Page 4 of 5 TIRSA Owner's Extended Protection Policy For A One-To-Four Family Residence(1-11-01)
New York
CONDITIONS(Continued)
ii. Any amount paid to the owner of the Mortgage shall iv. to You whatever is left.
be subtracted from the Policy Amount of this Policy; d. If You have rights under contracts (such as indemnities,
and guaranties, bonds or other policies of insurance)to recover
iii. If Your claim is covered only under Covered Risk 14, all or part of Your loss, then We have all of those rights,
15, 16 or 18, any amount paid to the owner of the even if those contracts provide that those obligated have all
Mortgage shall also be subtracted from Our Maximum of Your rights under this Policy.
Dollar Limit of Liability for the particular Covered Risk. 9. ENTIRE CONTRACT
e. We will pay any costs, attorney's fees and expenses which This Policy, with any endorsements, is the entire contract
We are obligated to pay under this Policy. between You and Us. To determine the meaning of any part of
f. If You do anything to affect any right of recovery You may this Policy,You must read the entire Policy. Any changes to this
have against someone else, We can subtract from Our Policy must be agreed to in writing by Us. Any claim You make
liability the amount by which You reduced the value of that against Us must be made under this Policy and is subject to its
right. terms,
7. OUR DUTY TO DEFEND AGAINST LEGAL ACTIONS 10. INCREASED POLICY AMOUNT
We will defend Your Title in any legal action only as to that part The Policy Amount will increase by ten percent (10%) of the
of the action which is based on a Covered Risk and which is not Policy Amount shown in Schedule A each year for the first five
excepted or excluded from coverage in this Policy. We will pay years following the Policy Date shown in Schedule A, up to one
the costs, attorney's fees, and expenses We incur in that hundred fifty percent (150%) of the Policy Amount shown in
defense. We will not pay for any part of the legal action which is Schedule A. The increase each year will happen on the
not based on a Covered Risk or which is excepted or excluded anniversary of the Policy Date shown in Schedule A.
from coverage in this Policy. We can end Our duty to defend 11. SEVERABILITY
Your Title under paragraph 4 of the Conditions. If any part of this Policy is held to be legally unenforceable, both
8. TRANSFER OF YOUR RIGHTS TO US You and We can still enforce the rest of this Policy.
a. When We settle Your claim, We have all the rights You 12. ARBITRATION
have against any person or property related to the claim. a. If permitted in the State of New York, You or We may
You must transfer these rights to Us when We ask, and demand arbitration.
You must not do anything to affect these rights. You must b. The arbitration shall be binding on both You and Us. The
let Us use Your name in enforcing these rights. arbitration shall decide any matter in dispute between You
b. We will not be liable to You if We do not pursue these and Us.
rights or if We do not recover any amount that might be c. The arbitration award may be entered as a judgment in the
recoverable. proper court.
c. We will pay any money We collect from enforcing these d. The arbitration shall be under the Title Insurance
rights in the following order: Arbitration Rules of the American Arbitration Association.
I. to Us for the costs, attorney's fees and expenses We You may choose current Rules or Rules in existence on the
paid to enforce these rights; Policy Date.
ii. to You for Your loss that You have not already e. The law used in the arbitration is the law of the State of
collected; New York.
iii. to Us for any money We paid out under this Policy on f. You can get a copy of the Rules from Us.
account of Your claim; and
Form 5032936(4-8-18) Page 5 of 5 TIRSA Owner's Extended Protection Policy For A One-To-Four Family Residence(1-11-01)
New York
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'compensadlon rfgim or obligations of sxy pang.•"
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, rLG
o,
specific proof of workers' compensation insurance coverage for such residen
appropriate box):
❑ I am performing all the work for which the building permit was issued. 272021
F RYE BROOK
❑ I am not hiring,paying or compensating in any way,the individual(s)thahgi A*rf 'Lo
for which the building permit was issued or helping me perform such work. V
❑ 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 indica`ted n the building p
n
Vl t Q �
(Signs of omeo vtsni.g88'V� tDate Signed) r p� ["
Home Telephone Number / 50 7J
(Homed er's Name Printed)
Sworn to before me this ?::�Z, day of
Property Address that requires the building permit: 7�2t
km) C�cie �
( ovn er of Notary Public)
AHN TED TAESHIK
Notary Public,State of New York
t657� No.01 AN6286995
1 ' Qualified in Westchester County
Commission Expires 08/05/2021
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