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HomeMy WebLinkAboutBP21-144PERMIT #�/ol�"" J��i ,_ DATE:_/� p(p;,SQ c� l.. SECTION J� L/• CoS BLOCK/ � LOT �J TYPE OF WORK � �r/Or �% �r�Q� e.�oVQ7�Grl JOB LOCATION e � Q� C 'mac/ OWNER Q/7'Q /!^u. •]� J�% Q ! � l0 8 "J`�o1s CONTRACTOR . �. C• C 7�✓QC % - /ro ,� pie � /5� day-5y58 EST. COST � � O®U - FEE � 3��' �� �CU # - FEES •' ` � DATE � c3 TCO # FEE DAfiE...�.._ INSPECTION RECORD DATE INSP FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING RGH PLUMBING GAS SPRINKLER ELECTRIC LOW -VOLT C� ALL+RM 0 AS PUILT O FINAL � _ � � / � �/aka �%kf��� /V y� ��' C���—�8 7/�Q CC�lyryJnc7 �Jec�iC OTHEf2 APPROVALS ARB - BOT PB ZBA OTHER VILLAGE OF RYE BROOK WESTCHESZ? COU1�1'l'Y, NEW YORK NO: 21-193 18;---�; Cattf irate of ®ccupaump 13his is to certify that A R1 At Coll'— of, R�(f BrM A)V having duly filed an application on 20 requesting a Certificate of Occupancy for the premises known as, r , Rye Brook,NY, located in a Zoning District and shown on the most current Tax Map as Section: J. Block: __L Lot: , and having fully complied with the requirements of the Building Code and the Zoning Ordinance under Building Permit No. C - 1- , issued tf� 2.0 , such authority and permission is hereby granted ILq- 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: - �V 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 heigh s d , r shall the building be moved from one location to another until a permit to accomplish such change has be ed oilding Inspector. DEC - 7 2021 Building Inspector,Village of Rye Brook: Date: 1 _ BUILDING DEPARTMENT PERMIT# DEC —Z 2021 VILLAGE OF RYE BROOK ISSUED:�D—/�!-a/ 9 8 KING STREET,RYE BROOK,NEw YORK 10573 DATE:_/c�—a—Zt VILLAGE OF RYE BROOK (914)939-0668 FEE: / 1 O— PAWA BUILDING DEPARTMENT APPLICATION FOR CERTIFICATE OF OCCUPANCY,CERTIFICATE OF COMPLIANCE, AND CERTIFICATION OF FINAL COSTS Address: job 73 Occupancy/Use:I—�i�✓L1 11 Parcel ID#: Zone: L!� Owner: 4141 f. / ot_ 4¢�YZ Address: P.E./R.A.or Contractor: C � Address: 7 Person in responsible charge: Address: �r it 't 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,C UNTY OF WESTCHESTER as: it being duly swom,deposes and says that he/she resides at C ? W-70 4 in t/.�_ 6 I(ZQgk in the County of �S in the State of ,that 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: + 0, o v 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 tmderstands 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. '( Swom to before me this -2 31 ' Sworn to before me is /J ' day of N(3 V rtil +b�l 20�� day of , Signature of Pro erty Owner ature f plicant L O i R t.'1`Tv Y�.R Print Name of Property Owner _ Print Name of Applican j� / S Y••_ PAMELA TRANS+ "' k"— Aitary Public.State of N&!';crK Notary Public NO.01 TR6125911 � Notary Public Quatifled in Westchest ty SANDRO LUKIC My Commission Expires %25 � u Notary Public-State of New York NO.01 LU63110T2 Qualified in Westchester County My commission Expires Sep 8,2022 �yE BR{�k• O�` tim • '9�� BUILDING DEPARTMENT ❑BUILDING INSPECTOR rlA SSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK U I ODE ENFORCEMENT OFFICER 938 KING STREET - RYE BROOK,NY 10573 (914) 939-0668 FAX (914) 939-5801 www.ryebrook.ore - - - - - - - - - - - - - - - -- - - - INSPECTION REPORT - - - - - - - - -- - - - - - - - - - - ADDRESS : A S- DATE: PERMIT# ISSUED: SECT: BLOCK: LOT: LOCATION: W y 1na OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS.,. �AC�CEPTED ❑ REJECTED/REINSPECTION ❑ SITE INSPECTION j Oc `kl 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 ❑'f,FINAL '❑ OTHER s z = z U I r, ai yy OD �f N N 0. ra Gt+ 9N` -t w P6o CA lot tn co ;Zl �..� •—� rf � V 3 � gz 0*4 � A cn o ►-� F" � � � z oc 40 06 Q � Q 16 a. r� 96 fat = BR �E �'ukDD BUIL MENT JUL 2 6 2021 VIL C�f) ,;BY K 938 KIN NY 10573 VILLAGE OF RYE BROOK (914)9 939-5801 BUILDING DEPARTMENT or ELECTRICAL PERMIT APPLICATION Westchester County Master Electricians License Required FOR OFFICE USE ONLY BP#: j-I EP#: Approval Date: Permit Fee: $ Approval Signature: Other: Disapproved: (fees are non-refundable) ********************* ********************** ************************************************** Application dated, 2 2 is hereby made to the Building Inspector of the Village of Rye Brook NY,for the issuance of a Permit to install allJor rkmove 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: SBL: Zone: Pu D 2.Property Owner: A4 Address: d to Phone#: �v" �+7��f �� Cell#: email: 3.Master Electrician: Alu b - GtC GL /Ji rl U Address: Lie.#: Phone#:T4—jAj- Cell41!Y-7al1j1/Co41 Company Name: �Gl �tiZC C� Address: f 4.Proposed Electrical Work/Fixture Count: e 4 L 1 74,,E STATE O%eC W YORK,COUNTY OF WESTCHESTER ) as: 6 Ou © being duly sworn,deposes and states that he/she is the applicant above named,and does further pri t na a of individual signing iA the applicant) state that(s)he is the legal owner of the property to which this application pertains,or that(s)he is the �GC�{ for the legal owner and is duly authorized to make and file this application. (indicate architect,c ntractor,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&Buildin ode,t the Village of Rye Brook and all other applicable laws,ordinances and regulations. Sworn fore me 2 Sworn to bef r me th� 2-3 da �.! day of ,20 2 ..�� t-SI gnature of Pro wn 1 Si a of Applicant kAj,¢L- v Al t rat! t Naide of Property Cfwner Print 14ame of Applicant STEyf NON NON No N VVI#j Ell •!T F NEW YORK Notary N c G 1 SEW0. Y No. 6 !30 Qualifl*d NC fttfr County pu01111* *vlor County My COMM i$$10 Exprrlls roper 14, 20.z3 It/y commi n Espoes October 14. 20714 "'- 3/21/19 Westchester Rockland Electrical Inspection Services, Inc. Phone: 914-347-3595 L r ADO NOT WRITE HERE-FOR OFFICE USE ONLY 43 North Lawn Avenue Fax: 914-347-3596 Elmsford NY 10523 r BUILDING PERMIT NO.. TEMP# DATE .^/[(/ +mil �j♦/� CITY OR VILLAGE ZIP CODE, TOWNSHIP COU TJ„ S r STFlEET AND NO.OR ROAM POLE NUMBER 4� - BETWEEN WHAT TWO CROSS STREETS IS PREMISES LOCATED? SECTION BLOCK LOT OCCUPANT'S NAME BUILDING OCCUPANCY "" /) DDRESS OWNER'S NAME AND A HOME TELEPHONE NUMBER -- ..5'� 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. IF. 2N°FL. 3'FL. VILIAGE OF RYE BROOK B 1J! -DING REMARKS:LIST OTHER ELECTRICAL DEVICES NOT SET FORTH ABOVE: f <0()-a& 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 1_1 ADDITIONAL CJ EXPOSED❑ CONCEALED 0 MUST ENTER APPLICANTS IDENTIFICATION NUMBER SERVICE ENTERS BUILDING OVERHEAD F� UNDERGROUND Ll -A I I I I AVOID DELAYS BY GIVING FULL AND ACCURATE INFORMATION.ALL SPACE MUST BE FILLED IN OR APPLICATION MAY BE RETURNED. NAME OF COMPANY OATE OF Z SIGNATURE OF APPLICANT t STREET ADDRESS- TELEPHONE NO. f 44 CITY OR POST OFFICE P CODE j� LICENSE NO.WHEN APPLICABLE WESTCNESTER RDCKUND ELECTRICAL INSPECTION SERVICES,INC. BY THIS CERTIFICATE OF COMPLIANCE THE Westchester Rockland Electrical Inspection Services 43 North Lawn Ave, Elmsford, NY 10523 914-347-3595 (Office) 1 914-347-3596 (Fax) CERTIFIES THAT Upon the application of: Upon premises owned by: Zaccagnino Electric Ranjan Munjal&Rittu Kapoor 81 Maple Avenue NY, Rye 10580 Located at: 19 Legendary Circle Rye Brook, NY 10573 Certificate Number: 1031504 Section:124.65 Block: 1 Lot: 15 BDC: Permit Number:EP:21-187-BP:21-1" A visual inspection of the electrical system at this premise described as a Residential occupancy,wherein the premises electrical system consisting of electrical devices and wiring,described below,located in/on the premises at: 19 Legendary Circle Rye Brook,NY 10573 Basement ®1st Floor 2nd Floor 3rd Floor Garage Attic Outside Other: Inspection was conducted in accordance with the NYS and NFPA 70-2017 International Electrical Code and detail of the Installation,as set forth below,was found to be in compliance therewith on 11102/21 Name Type Quantity Fixture-Luminaire Low Voltage 14' Puck Light 1 Fixture-Luminaire Recessed ------- 10 Dimmer 600 watts ------- 4 Receptacle GFCI ------- 5 Wine Chiller ------- 1 Refrigerator ------- 1 Dishwasher ------- 1 Disposal ------- 1 Cook Top ------- 1 Microwave ------- 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. VA N � o � o 0 Q! � i oL a ■ ■ 1!� N x f e- tom. � w �. � F y (w ■ F 0o Z G , • z ,'l mot 0-4 06 Ono oz w C7 � '"''* _ i oll .let C6 v z vi Q .. BUIL E' _ MENT Vu, E OF RYE OK JUL 2 8 2021 938 KIN "t:'T RvT:Bl ,NY 10573 (914)9 939-5801 VfLLAGE OF RYE BROOK w ' .or BUILDING DEPARTMENT PLUMBING PERMIT APPLICATION FOR OFFICE USE ONLY BP#: C I_/q Ll PP #: Approval Date: 2021 Permit Fee: $ k25 P-q(, Approval Signature: Other: Disapproved: (fees are non-refundable) Application dated, 7 �[ -� 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 he in conformance with all applicable Federal,State,County and Local Codes, 1.Address: `? r C17 SBL: ! c�`7 +�i: — Zone:�aaks 2.Proposed Work: 3.Property Owner: ! a yr Address: TC'� �� •r.�e Phone#: Cell#: tL''y�'�7 �'�oc3�S- email: 4.Master Plumber: I/ei� �,°cG Address: Lic. #:f Phone Cell#: email: p Company Name: /�11�/�(drl�fir A/7S` /sue Address: 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 1st Floor t ' 2nd Floor 3 Floor 415T loor 5--Floor Exterior 5.* List Other Equipment/Provide Details: rL��r ,��Y�s(�� b� S C 1; (Notarized Signatures Required Next 2 Pages) -y- 3/21/19 BUILD MENT � {I t VIL E OF RYYC OK D lJ 938 KING :E'r R Bt7 NY 10573 EL 2 $ OZ� (914)9 9 39-5801 •t Zw VILLAGE OF RYE BROOK ` /0 " BUILDING 'DEPARTMENT 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: T"T v residing at, 1 't t�IV ev\ dAl C t v cA e j�,Y'r— (I'rvit manic) (.lddrosv wlaerr ,u liar) Y f05 1`�j 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; O N 1) I_r Lt k �-�. , Rye Brook, NY. Oob 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. �'- (tii�nahnr nf I'r�y�crty(l�ancr(s)) -Tv 1'7 m (11riui N ime ol"Pnr per(y Owner(c)) Sworn to before me this .2 7 " I AMELA TRAN y wtary Public-State of No--.:-;k day©f 11 I l/ �� c� 1 NO.01 TR6126911 oPualffied In Westchester Cour (C*t- Q J rAay Commission Expires --:L'. �T (Notan,Puhlic) -3- 3/21/19 STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: Z t TTt) 1""A i? ,being duly sworn,deposes and states that he/she is the applicant above named, (print name of individual signirk 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 a Sworn to before e is day of ,20 a / day of ,20c'�A R, I Q2x--- �< Signature of Prop rty Owner Signa a of Applicant Print Name of Property Owner Print Name of Applicant p a ' I/L_ AoLk-' Notary Public Notary blip HhARI MELILLO Notary, State of Kew York No.01 ME6160063 Qualified in Westchester County Cammission Expires January 29 20 0� 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. 10tary Public•si:i i t- NO.01 rR612 S i OugUed in Westchest Co MV Commission Expires 7 oZ S _2_ 3/21/19 Building Permit Check List&Zoning Analysis Address: C1rLGt_ SBL: l74 • G-5: — � — Zone: Use: t.Type: V Other. Submittal Date: Lo Revisions Submittal Dates; Applicant; k— Al m D Nature of Work: t N Reviews:ZBA: PB: BOT: Other. hTXQ, OK ( ( ) FEES:Filing. 7��'�'�•. BP: Z'7o � "� c/o: Legalization: ( ) ( �APP: Dated ✓ Notarized: ✓SBL: ✓Truss I.D. Cross Connection: - H.O.A.: ( ) ( ) Scenic Roads: Steep Slopes: Wetlands: Storm Water Review: Street Opening: ( ) ( ) ENVIRO: Long Shorn 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 753#; Dated: N/A: HIGH-VOLTAGE ELECTRICAL Plans: Permit: N/A: Other. ( } ( ) LOW-VOLTAGE ELECTRICAL:Plans: Permit: N/A: Other. ( ) ( ) FIRE ALARM/SMOKE DETECTORS:Plans: Permit: H.W.I.C.:_Battery:—Other. ( ( ) 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: REQUIRED EXISTING PROPOSED NOTES APPROVED Am& r1ate,, � N 1 ones — liT `r unn i Cir Fm to a�C Front: E nv swz: �1� Man COV Accs.COV Ft,H Sb: Sd,H/Sb Tot.Imp ELIMP Pao Hei he Stori ; notes' 'sr` 'rt ►p '� ? 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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 be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME, peter Cuomo Valhalla Agency Inc C/O Northeast Agencies INC `A`,°N o 884_448 6B43 FAx 914-769-8516 6467 Main ST,Suite 104 E-MAIL ADDRESS: PoterCliOrrlO allstate.com Williamsville,NY 14221 N15U RER S AFFORDING COVERAGE NAIC tf INSURERA: Utica First Insurance Company INSURED INSURERS: _ Robert A Clementi INSURERC: DBA RAC CONTRACTING INSURERD: 17 HIGH POINT CIRCLE INSURER E: _ RYE BROOK NY 10573 INSURERFf COVERAGES CERTIFICATE NUMBER: 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 WTH 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, NSR ADDLTYP£OFINSURANCE INSO UBR POLICYNUMSER POLICY EFF POLICY UWTS LTRWVDI X COMMERCIAL GENERAL LIABILITY EACHOCCURRENCE 6 1r000,000 CLAIMSMADL XJ OCCUR PREMISES EaENT o=rrena S MED EXP(Any one n S 10r,000 A ART5072965 07=0320 07/30/2021 PERSONAL&ADV INJURY S 1,OW.000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 X —I- PRO- F71 LOC PRODUCTS-COMPIOPAGG S 2,000,000 OTHER: _ AUTOMDBILELUUMITY COMBINED SINGLE UNIT f Ea at �nt ANY AUTO BODILY INJURY(Per person) : ALL OWNED SCHEDULED BODILY INJURY(Per accident) S AUTOS NON-OWNED U76 AUTOS PROPERTY DAMAGE HIREDAUTOS AUTOS rIrD UMGREU ALAS HOCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE f DED RETENTIONS WORKERS COMPENSATION PERJER AND EMPLOYER S'LIABSLITY YIN - ATUTE - ANYPROPRIETORIPARTNER/EXECUTNE El NIA E.L.EACH ACCIDENT ti OFF ICE R/M EMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-FA EMPLOYEE _ K yes,describe under DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES(ACORD 101,Addt lonal Remarks Schedule,may be attached N more space Is required) CONTRACTNG SERVICES CERTIFICATE HOLDER CANCELLATION. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Village Of RyeBrook ACCORDANCE WITH THE POLICY PROVISIONS. 938 King ST AUTHORIZED REPRESENTATIVE Rye,NY 10573 Mary Norwood d 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD Yo K Workers' Certificate of Attestation of Exemption STATE Compensation from New York State Workers' Compensation and/or Board Disability and Paid Family Leave Benefits Insurance Coverage "This form cannot be used to waive the workers'compensation rights or obligations of any party.** The applicant may use this Certificate of Attestation of Exemption ONLY to show a government entity that New York State specific workers'compensation and/or disability and paid family leave benefits insurance is not required. The applicant may NOT use this form to show another business or that business's insurance carrier that such insurance is not required. Please provide this form to the government entity from which you are requesting a permit,license or contract. This Certificate will not be accepted by government officials one year after the date printed on the form. In the Application of Business Applying For: (Legal Entity Name and Address): Building Permit robert a clementi From:village of rye brook DBA.rac contracting 17 High Point Cir Rye Brook,NY 10573-1092 The location of where work will be performed is PHONE:914-937-0837 FEIN:XXXXX8554 19 legendary circle,rye brook,NY 10573. Estimated dates necessary to complete work associated with the building permit are from June 15,2021 to July 30,2021. The estimated dollar amount of project is $10,001-$25,000 Workers'Compensation Exemption Statement: The above named business is certifying that it is NOT REQUIRED TO OBTAIN NEW YORK STATE SPECIFIC WORKERS'COMPENSATION INSURANCE COVERAGE for the following reason: The business is owned by one individual and is not a corporation. Other than the owner,there are no employees,day labor,leased employees,borrowed employees,part-time employees,unpaid volunteers(including family members)or subcontractors. Disability and Paid Family Leave Benefits Exemption Statement: The above named business is certifying that it is NOT REQUIRED TO OBTAIN NEW YORK STATE STATUTORY DISABILITY AND PAID FAMILY LEAVE BENEFITS INSURANCE COVERAGE for the following reason: The business MUST be either: 1) owned by one individual; OR 2) is a partnership(including LLC,LLP,PLLP,RLLP,or LP)under the laws of New York State and is not a corporation; OR 3) is a one or two person owned corporation,with those individuals owning all of the stock and holding all offices of the corporation(in a two person owned corporation each individual must be an officer and own at least one share of stock); OR 4) is a business with no NYS location. In addition,the business does not require disability and paid family leave benefits coverage at this time since it has not employed one or more individuals on at least 30 days in any calendar year in New York State. (Independent contractors are not considered to be employees under the Disability and Paid Family Leave Benefits Law.) 1,robert a.clementi,am the Sole Proprietor with the above-named legal entity. I affirm that due to my position with the above-named business I have the knowledge,information and authority to make this Certificate of Attestation of Exemption. I hereby affirm that the statements made herein are true,that I have not made any materially false statements and I make this Certificate of Attestation of Exemption under the penalties of perjury. I further affirm that I understand that any false statement,representation or concealment will subject me to felony criminal prosecution,including jail and civil liability in accordance with the Workers'Compensation Law and all other New York State laws. submitting this Certificate of Attestation of Exemption to the government entity listed above I also hereby affirm that if circumstances change at workers'compensation insurance and/or disability and paid family leave benefits coverage is required,the abovmed legal entity wil i mediately acquire appropriate New York State specific workers' compensation insurance and/or disability and paid f ily ve benefits verage and also iinm ly furnish proof of that coverage on forms approved by the Chair of the Workers'Compensation Bo to f government tity bove. SHERE Signature: ;` Date: J /r Exemption Certificate Number Received 2021-035088 June 4, 2021 NYS Workers' Compensation Board , CE-200 0112018