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HomeMy WebLinkAboutBP21-136PERMIT # AD/6 SECTION TYPE OF WORK JOB LOCATIQN _ MMi'LL1 JF�40TiJL�Am EST. %/co # C T. SU DATE& 11 . 0 i // dori v lOT ®n FBOT aOTHER VALS 003\3/ t/ 663 ZBA OTHER oo iTE TCO # IFEE DATE INSPECTION RECOR DATE FOOTING FOUNDATION FRAMING RGH FRAMING � INSULATION PLUMBING RGH PLUMBING GAS SPRINKLER ELECTRIC LOW- JOLT Q 01 ALARM Q AS BUILT Q - FINAL INSP VILLAGE OF RYE BROOK WESTCHESTER COUNTY, NEw YORK � NO: 21-186 Certificate of Occupau.cp This is to certify that 6r c 0 W �Q0 o/ ?e YV of, Ryc Bpzy) r A! / having duly filed an application on �( 20 -?-/ requesting a Certificate of Occupancy for the premises known as, LZe22 I; r/� Dkf Ve , Rye Brook,NY, located in a - �oC Zoning District and shown on the most current Tax Map as Section: /,�, 6-6 Block: / Lot: , and having fully complied /with the requirements of the Building Code and the Zoning Ordinance under Building Permit No. C� issued 20 c2_ , 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: !"t /��i // , 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 b en o tained ilding Inspector. NOV 1 6 2021 Building Inspector,Village of Rye Brook: me: D E C� E� V E ,- - For office use only: f BUILD d�E�ARTMENT PERMIT# r/ 4 VIL)frE OF RYE BROOK ISSUED: NOV "5 2021 938 KING STREETa� VE BROOM(,NEw YORK 10573 DATE: VfLI AGE OF RYE BROOK (914)9 0668 FEE:cats' j/0 — PAIDIef BUILDING DEPARTMENT �+w v 3 raok.orU APPLICATION FOR CERTIFICATE OF OCCUPANCY, CERTIFICATE OF COMPLIANCE, AND CERTIFICATION OF FINAL COSTS TO HE SUBMITTED ONLY UPON COMPLETION OF ALL WORK, AND PRIOR TO THE FINAL INSPECTION Address: '1ry� t 1 ti , Occupancy/Use: I—r,,¢PV Parcel ID#:_ Zone: —/c Owner: 4; G(`1 —pa\1yc.j Address: 06 �It + l T—'X t\,R P.E./R.A. or Contractor: 00 Person in charge:e res onsibl C�tecae`u �epca I�t p g 5 Q.z uu>s>�Ic�c e� Address: '`jGN'\e a ---, 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: cc>vI c"I being duly swom,deposes and says that he/she resides at 1 ^( �I't 11 (Print Name of Applicant) (No,and Street) in tar t in the County of e Sy\ (^ in the State of that (Cityrrownl 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:$ V�> d a 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.of the Code of the Village of Rye Brook. Sworn to before me this LA Sworn to before me this day of , 20 day of , 20 �'(,�VIcS7.cr Signature of Proper6bwrier Signature of Applicant print Name of Property Owner Print Name of Applicant �-"ALE� MARSHALL Notary Public Notary Public,State of New York No.o1FR6363711 Qualified In Westchester County �'�, , }� Commission Expires August 28,20 1982 BUILDING DEPARTMENT ❑BUILDING INSPECTOR SSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK CODE ENFORCEMENT OFFICER 938 KING STREET • RYE BROOK,NY 10573 ex (914) 939-0668 FAx (914) 939-5801 wwwxyebrook.org - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - � v rU ADDRESS :- ATE: t� PERMIT# ISSUED: SECT: LOCK: LOT. LOCATION: C ``` OCCUPANCY' VIOLATION NOTED THE WORK IS... ACCEPTED ❑ REJECTED/REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING p ROUGH FRAMING ❑ INSULATION NATURAL GAS ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING CROSS CONNECTION Q 4INAL ,f[] OTHER lm 1932 BUILDING DEPARTMENT ❑ ILDING 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 :- L�_ C ��n �--V-ffl V✓' � \+- DATE: k � PERMIT# A - ISSUEDkD I SECT: BLOCK: LOT: LOCATION: OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... p ACCEPTED 0 REJECTED/REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: }''ROUGH PLUMBING ROUGH FRAMING ❑ INSULATION ❑ NATURAL GAS N 1E-� '•t 4 • �� ^ j ❑ L.P. GAS FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER r V L1nA W . � N N N � eq N �, oC tn s pl tn p a tn .. cn aid mot M > _ w a 4i F W r 0 ■ �i � �" o � W F w � ` E Z c w Q � _ C6 wr O w Ncc or co 00.0 Ono 00 v F C'7 o F � U a, zOd U W „ U Cw7 OQ F. © CL, M. a = w ° < z p � QC BUILDING DEPARTMENT JUL - 7 2021 ID VILLAGE OF RYE BROOK 938 KING STREET RYE BROOK,NY 10573 VILLAGE OF RYE BROOK (914)939-0668, AX(914)939-5801 BUILDING DEPARTMENT vwwv.'.r red gok-org ELECTRICAL PERMIT APPLICATION Westchester County Master ,E+lectricians License Required FOR OFFICE USE ONLI BP#: pD/—/,34 EP#: Cp Approval Date: Alli _ R in2i Permit Fee: S Approval Signature: Other: Disapproved: (fees are non-refundable) Application dated, 0 _O(o 1 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. I.Address: /9 &�w a i l l 12rlt/L'. �Ye B►y04 SBL: 13 5.15 0 2.Property Owner: 54UCtl 1'10U1 &F - DanvU/ Address: IOp E 1 W #d l poli12r Rye 8r7i k N7 IQ - Phone#: Cell#- / I '(O 0 _email: 5 0Y.5 ee»7G Yu Al •(:Qdj 3.Master Electrician: (,rly4�'-"Vd W') Sa9r 0t./ Address: 13 titan t) NEW 90e I!t, lle- N1 /t &).- Lie.#: I ZZ Phone#: Cell zzjry email: Lase r FLed Y iL LLe r��jVA; fpy�/ Company Name: tc,5Yr Ftec�t, ✓ rj��tCr� Address: 1.34 ftlkiw- � Alew A(Atet�[r �ll 4.Proposed Electrical Work/Fixture Count: �it LAJ (1)`14)0� Fb-e Te fZ R) STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: ,being duly sworn,deposes and states that helshe is the applicant above named,and does further (pnra mine of tndn saremng as the applmm) 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. t wdtcsre arelumm convenor,ap m,anornec.etc.) The undersigned fitrther 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 of the Village of Rye Brook and all other applicable laws,ordinances and regulations. � Sworn to before me this -7/-"? Sworn to before me this 17A day of ., 202-1 _ day of 15z, 20 sr Signature f o erty Owner Signatur o App' tt h�irv0 t Gt 1lY9�`7r'6�Ifk, Print Property Print N of Applicant Notary Publi N tary Pu Peter,fordnn 131r+ntr_ Peter Jordan Glantz Notary Public, State of New York Notary Public, State of New York No. 02GL6138711 No. 02GL6138711 (qualified in New York County GZualified in New York County 3/21i14 Commission ExpiresL'Rf- — Commission Expires Westchester Rockland Electrical Inspection Services, Inc. « Phone: 914-347-3595 DO NOT W91TE HERE—FOR OFFICE USE ONLY � 1 43 North Lawn Avenue �� Fax: 914-347-3596 NY 10523 Elmsford, � A `r BUILDING PERMIT NO. TEMP 8 DATE CITY OR VILLAGE ZIP CODE TOWNSHIP COUNTY G' -k STREET AND NO.OR ROAD POLE NUMBER I tl BETWEEN WHAT TWO CROSS STREETS IS PREMISES LOCATED? SECTION BLOCK LOT OCCUPANTS NAME BUILDING OOCUPANCY 1 OWNER'S NAME AND ADDRESS n HOME TELEPHONE NUMBER CURRENT SUPPLIED BY FROM THEIR OFFICE WORK TELEPHONE NUMBER LIST BELOW ALL EOUIPMENT 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 .'''� I LI (' BASEMENT 1 L� � 1° FL r 2" FL 3'^FL. _ VI LAGS F RYA ROOK B ILDIN D 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 RAVE 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 C UNDERGROUND AVOID DELAYS BY GIVING FULL AND ACCURATE INFORMATION.ALL SPACE MUST BE FILLED IN OR APPLICATION MAY BE RETURNED. NAME OF COMPANY DATE OF APPLICATION SIGNATURE OF APPLICANT STIEW ADONBtB TELEPNw NO. CRY OR POST aFFxx UCGWNO.YIM04 APPLICABLB �Q 7 z WESTCHESTER 71 ROCKLAND ELECTRICAL INSPECTION WRE15SERVICES,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: Laser Electric Services Bret&Stacy Danow 137 Pelham Road NY,New Rochelle 10805 Located at: 18 Elm Hill Dr Rye Brook, NY 10573 Certificate Number: 1030620 Section:135.50 Block: 1 Lot: 56 BDC: Permit Number: EP:21-165-BP:21-136 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 inlon the premises at: 18 Elm Hill Dr Rye Brook,NY 10573 I I 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 09113121 Name Type Quantity Receptacle Convenience ------- 1 Receptacle GFCI ------- 1 Switch Wall ------- 4 Exhaust Fan Bath ------- 1 Fixture-Luminaire Recessed ------- 5 Fixture-Luminaire Vanity Light ------- 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. ! TA � a .� ao C N N N M � pF r a, x U w 00 to u Gzl M M Z I � m = c �- a ,O o . ?- w � N V W z w Z �: eqrINO �jT �w z W 000 � cisZ Z a 4 * Q rn r CN Z p4 � Qy D u d i tea., Q CS x c. x _ , m U x rr+ d � c •• � �, � � ar � OC RBUILDING DEPARTMENT FJUL 11 ���� VILLAGE OF RYE BROOK 938 KING STREET RYE BR(x)K,NY 10573 VILLAGE OF RYE BROOK (914)939-0668 FAX(914)939-5801 BUILDING DEPARTMENT www.ryebrook.org PLUMBING PERMIT APPLICATION FOR OFFICE USE ONLY BP #: c>l '/ 34;p PP#: C;)/— //I Approval Date: J U L 1 4 2021 Permit Fee: $ Approval Signature: Other: Disapproved: (fees are non-refundable) ***7Application dated, / is hereby made to the Building Inspector of the Village of Rye Brook NY, for the issuance of a Permit to install an rem ve Plumbing as per detailed statement described below. The applicant&property owner, by signing this document agree that said plumbing work will be in conrormance with all applicable Federal,State,County and I.ocal Codes. L Address: I SBL: I `�r Q`��'" [�a Zone: —1 4 2.Proposed Work: � s 3.Property Owner:: Q VM)A% 5j" Address: Phone#: Cell#: CM"-I (�P- (OL�l 0 email: 4.Master 'Plumber: ��[ 1 1 Y i-'13 Address:40 k' 'n� W1 f Q_ 1�Lie.#: r)}Phone �]#_:, `� 1� _Cell#:q H `5�+-l�,r� mail: 4 �y�,r3r',c. Company Name:C1 RUJ 11a1 l�J j tj4jft CQJ_'?Address: 'AC) �dw I (we 11 ►k a NI In I INDICATE FIXTURES& LINES TO BE INSTALLED AS PER THE FOLLOWING SCHEDULE: Location Water Urinals Drinking Sinks Showers Bath Laundry IX)mestic Fire Sanitary Natural/ Other* Total Closets Fountains Tubs Tubs Service Service Sewer LP Gas Basement 1st Flom 2nd Floor .z 3'd Floor 4'h Floor 511 Floor Exterior 5.* List Other Equipment/Provide Details: (Notarized Signatures Required Next 2 Pages) _t. 3/21119 STATE OF NEW YOM COUNTY OF WESTCHESTER ) as: �j i �,- BSc a11hr�,being duly sworn,deposes and states that he/she is the applicant above named, (print name of individual signing as the applicant) and filrther states that(s)be is the legal owner of the property to which this application pertains,or that(s)he is the _C� i4,,rc C 1� �,,� 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 13 Sworn to before me this I day of 7U 20 21 day of J LA 20� Signature oftfoperty Owner KihWe, pplicant ,S&V-"4 b ck-o o CJ �Z'te'q"� O—A Print Name of Property Owner Print Name of Applicant Notary Pub ' mr— No Peter Jordan Glantz Notary Public, State of New York JACQUELINEAVERE No. 02GL6138711 NOTARY PUBLIC,STATE OFNirWYoRK Qualified in New York Coun R � 016 Commission Expires 17ec,.?�'�1 � Qw i Duubm Cmni This application must be properly completed in its entirety and must incl e(R�RvmwFeix=Y3, t 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 DEPARTMENTJR VILLAGE OF RYE OROOK ,JUL, 14 2021 - LDI 938 KING SIFT RYE BRc ,NY 10573 (914)939-0668 FAX(914}§39-5801 VILLAGE OF RYE BROOK BUILDING ©EPARTMENT wwwxyebrook.or<; _ 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 PLUMBING PERMIT APPLICATION. ANY BUILDING OR PLUMBING PERMIT APPLICATION SUBMITTED WITHOUT THIS COMPLETED AND NOTARIZED FORM WILL BE RETURNED TO THE APPLICANT. STATE OF NEW YORK, COUNTY OF WESTCHESTER ) as: residing at, 1�) E k (PIinl nruurl (Addres,whorl'vou li,,c) lcaS� 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; y� &" \A.11\ , Rye Brack, NY. 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. Z&A��74)e��� - (SigliatUrC of Propaly I1 ncri,I I (Print Nang l l'r �nrl 17t513Ci{:till Sworn to before me this (`-) day of 2 roar+'Public) ALEXANDRA H.FRANK (;q7"VW 1 Notary Public,State of New York No.01FR6363711 Qualified in Westchester County commission Expires August 28,20 .L _3 3/21/19 Building Permit Check List&Zoning Analysis Address: SBL; Zone." L- ��— Use Consn Type: 3 Other. Submittal Date: 1 -L Revisions Submittal Dates: Applicant: .L`.N o_. Nature of Work: I I.3 �1 rtr+4 u} i 7 Reviews:ZBA: J — 02 1 PB: BOT• Other. OK ( ( ) FEES:Filing .T BP: Zz 5- 'f C/O: Legalization: ( ) (.�APP: Dated: ✓ Notarized 'SBL: G Truss I.D. Cross Connection: `—' H.O.A.: ( ) ( ) Scenic Roads: Steep Slopes: Wetlands: Storm Water Review: Street Opening. ( ) ( ) ENVIRO:Long Short: Fees: N/A: ( ) ( ) SITE PLAN:Topo: Site Protection S/W Mgmt.: Tree Plan.: Other: ( ) ( ) SURVEY.Dated: Current: Archival;- Sealed: Unacceptable: { ) ( ) PLANS:Date Stamped: Sealed: Copies: Electronic Other: ( ) ( License: '�Workers Comp; '� Liability "Comp.Waiver Other. ( ) ( ) CODE 753A Dated: N/A: ( ) ( ) HIGH-VOLTAGE ELECTRICAL:Plans: Permit N/A: Other. { ) ( ) LOW-VOLTAGE ELECTRICAL:Plans: Permit: N/A: Other. ( ) ( ) FIRE ALARM/SMOKE DETECTORS:Plans: Pen-nit: H.W.I.C.:_Battery:_Other: { ( ) PLUMBING:Plans: Permit: Nat. Gas: LP Gas: N/A/: Other. { ) ( ) FIRE SUPPRESSION:Plans: Permit N/A: Other. { ) ( ) H.V.A.C.: Plans: Permit N/A Other. ( ) ( ) FUEL TANK.Plans: Permit: Fuel Type: Other. ( ) ( ) 2020 NY State ECCC: N/A: Other. { ) ( ) Final Survey Final Topo: RA/PE Sign-off Letter; As-Built Plans: Other. ( ) ( ) BP DENIAL LETTER: C/O DENIAL LETTER Other. ( ) ( ) Other: ( )ARB mtg. date: approvaL notes: ( )ZBA mtg.date: approvaL notes: ( )PB mtg. date: approval notes: REOUMED EMMN PROPOSED N� APPROVED Arm: lutes: _ UN _ `1A91 Main Goo Acss�s Ft.H✓Sb: Sd.H _GEA: Tot, Pasktal6 HhclSts>xies: notes: .l �� �� � .��r}'•..r•^ .jF(� �� S. rl} �' � 1 fin, a� lee,e 01l/111!j S ' Q. tj i i'ri 1 rn f C a+ iv .. N o �? bCV ttiGs)R O41 9 ♦�y� G • c1.1 iM y o o tection w c� CL Ica �fiTi� F V, z w m z p a :� a y G �L =• ►. w U N 7— 0 0 4 : ca Z 11 lli\ Cd = U coC14 TO rj M CA C%4 en sA U .6 C + t J• I`Y . �4 . 111; Ij! •i µllf'frl! + , llsf/!f! � �!1lrfrll .1lrrfll ''•r�lilrll 1 1'�11�! '��� J, y f i .. si f i y ►•�� �f0� f r f ��li `'�dl•� rt�.it� '4.+.+•�s►a . � '.'•� � . -.�ciuEa��dk��•$r�''� ",�w'�" "='" 1..+$>'��'� ,,rY -w'r..,.y• - .Y.=-''�n'��e:S��:Mw'�"'��i��1'4r:�Y"'�n ; Acm CERTIFICATE OF LIABILITY INSURANCE DA7THiS THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLCERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THEBELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AU REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: !f the certificate holder is an ADDITIONAL INSURED,1 pollcy(ies)must have ADDITIONAL INSURED Provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the poficy,certain Policies may require an endorsement, A statement on this certificate does not confer ri hta to the certificate holder in 11eu of such endorsementiaf. PRODUCER Jahn M Donohue FITZPATRICK INSURANCE CENTER NAME 54 WELCHER AVENUE . 914 739.6117 914.739.1553 PEEKSKILL.NY 1056E JOHND�FITZPATRiCKINSURANCE.COM --- I"s— !1-ePrumulowisilrtoc wueP wSURER A. EVANSTON INSURANCE COMPANY INatRtso Florem General Repair llie - - - - _ _,.._ 35379 P O Box 1902 INaURER a_ _ Ossining.NY 105U INSURERC: RIWRERD - -- -..-. .. _ _ . - - - -- INEURERE - __ COVERAGES w RERF. - -- - -- - ------- --- --- CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POUCIE5 DF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTIMTT STANDING 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 CONDITIONIS OF SUCH POLICIES.LIMITS$HONM INMAY HAVE B€EN REDUCED BY PAID CLAIMS. I TYPE OF INSURANCE ---- - - �MucrEi SveFv POLICY NUMBER idea A COMMERCDILGENERALLU1eILITY IY 3AA474748 Ut,ub,2021 051DO12022 ERCIIQRENCE E 7,0OQ,1 ..%uMSMAt)E �1f OCCUR a 100.000 — _ -..-- MEDEIP A olr .cart S 5,000 - PERSE7NAL9 AOV INJURY s 1.000.000 OSNL AOfIlanf�l``A'�1�E LPw11R�1pp1..APPLIES PER GENERAL AGOREtLITE a 2.,tXX3,00p .. POl.X:1f L�J JECT LDC PRODUCTS-O IMPIOP AOG i 2,000,000 T"Ill -— _ AtITOMpaItE IlMa..l1'r a rlvv AUTO .1Ea - a OWNED SCHEDULED 600ILT INJURY IPM PrWIII S AUTOS CHIT AirTOfi 'BOpIY INJURY IP.r.00iy.Al) S HIRED AUTOS ONLY ANUTpBO ONLY P S Par Rc a i UMMRLA Ul OCCUR II OCCURRENCE a utcmLIAB CWMSrn1AOE GED j RETENTION S YMORRlRa CYIMPEN.T. ; ANO EMPLOYERS'LIill Y I N ,ANY PROPRN:TORIPARTNERrEA£CUTIVE •OFFICERAIHEIER EXCLUDI NIA E L EACH ACCIDENT S lrarleMsal M L _ - --- N .rpYiON OF r E l D14EASE EA EMPLOYEE I RIPTION OF OPERATIONS pelprr E L.DISEASE•POLICY LIW T 1 i DESCRIPTION Or OPERATIONS I LOCATIONS I VEHICLES Al 101,Aemeoryl RemuR.Schtl may r+.anaceea If more ePace 1.r"UUMI - LIST CERTIFICATE HOLDER ASADDITIONAL INSURED JOB LOCATION 18 ELMS HILL DRIVE,RYE BROOK,NY 10573 CERTIFICATE HOLDER CANCELLATION ANY OFVILLAGE OF RYE BROOK BUILDING LD DEPARTMENT THE U EXPIRATIONH DATE DESCRIBED NOTICE IEWILL CANCELLED DELIVERED RN 983 KING STREET ACCORDANCE WITH THE POLICY PROVISIONS. RYE BROOK.NY 10573 AUTHORIZED REPRESENTATIVE lI 14i45\ 1986-2015 ACORD CORPORATION. All rights reserved- { ACORD 25(2015103I The ACCI name and logo are registered marks of ACORD NYSIF Now York Stam Iniuronto FYnd WESTCHESTER ONE 44 SOUTH BRCADWAY,10TH FLOCK,WHITE PLAINS,NY 1 060 1-44 1' nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE o. 'a """""" 262545639 FITZPATRICK INSURANCE CENTER 54 WELCHER AVE PEEKSKILL NY 10566 []i SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER FLORES GENERAL REPAIR INC PO BOX 1902 VILLAGE OF RYE BROOK OSSINING NY 10562 BUILDING DEPARTMENT 983 KING STREET RYE BROOK NY 10573 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD W2296 223-7 953596 DATE 081241202C TO 08124/2021 5127i202' THIS PS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YURK STATE INSURANCE FUND UNDER POLICY NO. 2256 223-7 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS COMPENSATION UNDER THE NEW YCRK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THESTATE OF NEW YORK. EXCEPT AS INDICATED BELOW, AND. WITH RESPECT TOOPFRATIONS OUTSIDE OF NEW YORK. TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUOING ANY NOTIFICATION OF CANCELLATIONS OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTPS:IAVWW.NYSiF.COMICERTICERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THIS POLICY DOES NOT COVER CLAIMS OR SUITS THAT ARISE FROM BODILY fNJURY SUFFERED BY THE OFF{CERS OF THE INSURED CORPORATION PRIES SERGIO FLORES FLORES GENERAL REPAIR INC THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NDT AMEND. EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY, NEW YORK STATE INSURANCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER;823482444 U-26.3