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HomeMy WebLinkAboutBP21-145PERMIT # �� SECTION TYPE OF WORK 10B LOCATION GThIER APPROVALS � DATE: �� �I p(P: J� e�c�- ARB BOT , _ 3 BLOCK LOT � �" /,O/' 2.7©�/Q ,� ZBA _ � � _ . � _ �_ _ _ i OTHER — • • �rlL_��15lTii�l���`/1,�1��1.[i�LJ • - �. INSPECTION RECORD DATE FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION � i � PLUMBING RGH PLUMBING GAS SPRINKLER ��3,a' ELECTRIC LOW -VOLT ALARM AS BUILT � �'�'� FINAL _ 1NSP 3 �.�/1�.��1�,�� �9/ ��907- 378 � ���� P���-la��� �1�M6;-�y .� ���n� Expired Letter Sent 10/6/2022 �r�d col iq Jaa VILLAGE OF RYE BROOK WESTCHESTER COUNTY, NEW YORK 4W` NO: 22-167 Certificate of ®ccupaucp This is to certify that A of, RV� &60144 AJ 7 having duly filed an application on a-/-o ter le). 20 requesting a Certificate of Occupancy for the premises known as, Rye Brook,NY, located in a RaF Zoning District and shown on the most current Tax Map as Section: �. 3 Block: / Lot: and having fully complied with the requirements of the Building Code and the Zoning Ordinance under Building Permit No. �� , issued 20 02I, such authority and permission is hereby granted to the property owner to lawfully occupy or use s id premises or building or part thereof listed under the following New York State Classifications, Use: w-i J n e- ) Construction: TM for the following purposes: l IJ 1 ( �'v to V IL.i-h—IJ-7C_/n 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 hei t s 11 be in11 the building be moved from one location to another until a permit to accomplish such change has en ed fr m the Builft Inspector. - 3 2022 Building Inspector,Village of Rye Brook: Date: %2,ERTIFICATE BUILD y�~ Y' NT For office use only: . ': PERMIT# VIL 4tYE: OK ISSUED: KING SIRE 31 .B<tQtOTCt YORK 10573 DATE: - -~ �� »Qd QY 000, FEE: PAID w ro E 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 #*+rstswsrssrsssts#rr*t*s(�#rsrrrlrrr+rs*ss+*r#*,*,#r#twrsrrrrrrsr►k r +r+r+**r*t#rrrss**►rr*++r+#rrrr#rrr rrsrs#+r*#r*a*ssrs*+++##s Address: U1 gro c7 l`I`d ""t Y{' i1,Q �l?3 0 /C - - Occupancy/Use: Parcel ID#11: "-�`A# 1/3 /- 7q Zone: Owner:_LP/J O IQ..P. Atf S S i'n �u Address:,! P.E./R.A.or Contractor: L' N�/\MlN eccc guM),,W-l`Address: 9c6- Lcxw—a C'1 eo- whil-e PlalnS NN lCx00'4 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 YORK,COUNTY OF WESTCHESTER as: 2 `e ' 1 �tie .0 LS lf}+'1� being duly sworn,deposes and says that he/she resides at�� l�Ol�-'!rl•--I�Q C�z- (Print Name of Applicant) (No.and Street) ! l� in 1�V P �j(1�� r1; ,in the County of in the State of IU that —T' (City/rows/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 f� I have been donated gratis was:S ") ()Oo for the construction or alteration of: i=l ith t°n i'e0G\/QI-h 7 n I 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. tilfll Sworn to before me this ���- \ sworn day of ,20 Z d ••�vc��•• . '��� 0 ZZ_ Z ��� STATE %2 i OF NEW YORK • &te ropcny Owncr isn ffjkRVtPUBLIC )�e.S 5�n eQualifiedin`BronxCaunty0 ON 1) Print Name of Property Owner i�ltjp a of Appli alit •+ �•�� ' •• •• lie ],IV,IIIitI�, •�5 �yE 13RC�k. 1982 BUILDING DEPARTMENT ❑BUILDING INSPECTOR ASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK ❑CODE ENFORCEMENT OFFICER 938 KING STREET • RYE BROOK,NY 10573 (914) 939-0668 FAx (914) 939-5801 www.Uebrook.org - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS :_ V (3f oa Aov (A DATE: PERMIT# 02 'z�- ISSUE `-' SECT:1 1 , q-3 BLOCK: I LOT: LOCATION: l \�-tt �"i y � '� � OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... ,[ACCEPTED ❑ REJECTED/REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ NATURAL GAS ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑/�ROSS CONNECTION g I'INAL /❑ OTHER �yC,DRC�k a �m cu � 1982 BUILDING DEPARTMENT J0BUILDING 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.ors - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS :— ' �� L DATE: -Z PERMIT# � ISSUED: SECT: BLOCK: LOT: LOCATION: 1�/ ti � S V OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... ACCEPTED ❑ REJECTED/REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ ,UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ NATURAL GAS ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER i s O s to s � O C4 N C � m c i O O t yr O cn w N z o O z W a = �- � oo w o y00o 3 � a 6. A -OltLi O U •• z O Uo O C4 w - 2u U _ rW O z .� oo •- w �n W Z ce c Z a/ �o ononow o f Z ON z y p a f Q w 5 � V a Q 3 tin �. �- '_' z _ 3 U o 0 Q w v, 8 � o C Z 46, U G an ` I c1 Gw. Mi Q6 2 can �� D BUILD/IN<a����$/ _ MENT VILLAGE OF RYE BRpOK J U N 3 0 2021 938 KING STREET RYE B ,NY 10573 VILLAGE OF RYE BROOK (914)939-0668 FAX(914)939-5801 BUILDING DEPARTMENT wwwxy ook.org ELECTRICAL PERMIT APPLICATION Westchester County Master Electricians License Required FOR OFFICE USE ONLY BP#: c:) /- EP#: 0 Approval Date: JUN 3 U mn Permit Fee: $ Approval Signature: -' Other: Disapproved: (fees are non-refundable) ****************** ***** ************************************************************************* Application dated, '3� c� 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 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. /� L Address: p V�</ C 0 u' +- SBL: 1l1 .43 - ( - 7 c Zone:. l> 2.Property Owner: L e-✓l cC)/p 6i l j o L�Gv�I✓J Address: L �,,�aol�✓e Y C Q �� Phone#: Cell#: 9 l-7- 6 � ( - 7 O�3 email: 3.Master Electrician: G11^/ \ �0 w c,- I y.5 Address: 9 C (L'es f I pa or'V7 Lic.#: 1�I Z Phone#:ft"I OYZ-rx.-U_I-I Cell#:cj C Y3 L�--3 B a-I email: P(y l,f " 163 CompanyName:r✓L/\/,n Address: 4-e 4.Proposed Electrical Work/Fixture Count: 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 me this day of 120 day of 20 Signature of Property Owner gig-nature of Applicant Print Name of Property Owner Name o Applican Notary Public Notary Public SHARI MELILLO Notary Public,State of New York No. 01 ME6160063 Qualified in Westchester County? ComrnisGion ExnirQs.hrn ipn'94 20!// 3/21/19 • STATEWIDE INSPECTION Service With hitegrity 121 Main Street,Fishkill, NY 12524 1 email:office@swisny.com SWIS JOBAPPLICATION12.72241 fax9l4.219.10621 • • • Office Use Elect. Permit# Date Bldg Permit# Utility ID# Final Certificate# City/Village Zip Township County Address Cross Street Section Block Lot Owner Name/Address(If different than above) Contact Number ❑Basement ❑ 1st FI. ❑2nd FI. ❑3rd FI. ❑More Than 3 FI. ❑Garage ❑Attic ❑Outside ❑Residential ❑Commercial Receptacles Special Recept GFCI AFCI Switches Dimmers Smoke Alarms Carbon Monox Hood Trash Compact Amt Amps Range(s) Cooktop(s) Oven(s) Dishwashers Refrigerator Disposal Microwave Warm Draw Incandescent Fluorescent SERVICE Amperage Voltage 1P 3P #Meters #Disconnect ❑Underground ❑ New ❑Reconnect ❑Overhead ❑ Change ❑Visual Re-Inspection ❑ Safety Re-Inspection ❑ Re-Inspection Additional Information D [EC IEWE DD JUN 3 0 2021 VILLAGE OF RYE BROOK BUILDING DEPARTMENT This application is valid for one(1)year from the date received by SWIS.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.The applicant declares that there is no open applications for the above address with any other inspection company.The applicant,owner or authorized agent agrees to all the above terms and conditions as set forth for the application. Inspector Date Finalized Inspector# Company Name C/O." ( Date Signature Address ? L ��;�v� 1 City/State Zip Code License# / ,a / Z Phone# State Wide Inspection Services CA-C) 1080 Main Street Fishkill, NY 12524 U S 845 202-7224 Phone wri914-219-1062 Fax STATE WIDE INSPECTION SERVICES Email: officegswisny.com Website: www.swisny.com Service with Integrity BY THIS CERTIFICATE OF COMPLIANCE STATE WIDE INSPECTION SERVICES CERTIFIES THAT: Upon the application of: Upon Premises Owned by: CMM Power Plus Lenore Alesandro Marc Mancini 16 Brookridge Court 36 Reservoir Road Rye Brook, NY 10573 North White Plains, NY 10603 Located at: 16 Brookridge Court, Rye Brook, NY 10573 Section: Block: Lot: Electrical Permit Number: EP21-160 141.43 79 Certificate Number: 2021-6725 Building Permit Number: BP21-145 A visual inspection of the electrical system was conducted at the Residential occupancy described below.The electrical system consisting of electrical devices and wiring is located in/on the premises at: 16 Brookridge Court, Rye Brook, NY 10573 The First Floor Kitchen was inspected in accordance with the NYS and NFPA 70-2017 and the detail of the installation,as set forth below,was found to be in compliance on the 23rd day of December 2021. Name Quantity Rating Circuit Type Pendant Lights 02 Switches 06 Counter Top Receptacles 07 Officer: Frank J. Farina This certificate may not be altered in any way and is validated only by the presence of a seal at the location indicated.This certificate is valid for work performed on the date of inspection only. i a � N d W N Z a oe ° it v M W c, all = e W I� Mw � z o Z w � S � � Fes• py 3 a 3 .. W A x LL) � t o O oc W Z CY. �..� U r • � M � � 00 qT o ~ 2 � zCIS 00 z w �" . 96 a � A ` �I 0' C. .a f� Gi. 2 � • c t_ r e 4u� ab �� DD , BUILDING DEFMENT VIL A�EEDF RYE��OOK938 KINO, T RYE B"j ,NY 10573 JUL 3 0 2021 (914)939; b AX�"(�h4)939-5801 w1. , VILLAGE OF RYE BROOK PLUMBING PERMIT APPLICATION BUILDING DEPARTMENT FOR OFFICE USE ONLY BP#: cp I'/�1'155 PP#: C>-I d 3 Approval Date: AUG ZJP21 Permit Fee: $ Approval Signature: Other: Disapproved: (fees are non-refundable) ****************** **** ************************************************************************** Application dated, 3�) is hereby made to the Building Inspector of the Village of Rye Brook NY, for the issuance of a Permit to install anclAr 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 conformance with all applicable Federal,State,County and Local Codes. 1.Address: �1p b✓oo K V Uqe Cou Y SBL: 14143 7 / Zone: Oec�-,C 2.ProposedWork: P—te QC Ingj k-I�cFlev, olx}-vv­c.s I >S Jct IC,�rv. St^K- 3.Property Owner: Le✓10✓2 l4(e59gnd✓0 Address: IC by00KY/ 9! Cauvv Phone#: Cell#: 917-L/l 081— 7o93 email: t Q.r-1 2 q9 Q h'4Maj. CC►yl 4.Master Plttmber: C,eS4veC) 'T"��a Address12 e,6 Spv,S. ,&W tz,).v­)MyA ply{ [aE23 Lic.#: ►t{S 5 Phone#:64 Io- 239 4. Cell#: email:i`jt4 bl rl 9 L L C 6 Ct-mq'j, C O rY\ Company Name: t-�Q�1 u M t Address: 12-0 SCAvS �Pl M fOY J N 4 la 5 23 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 I 2nd Floor 3'd Floor 4' Floor S"Floor Exterior 5.*List Other Equipment/Provide Details: FPp ci Clftq 4k�ey\ plxluYP� yi shwcdLt"V- tlkupr\ CgUQT (Notarized Signatures Required Next 2 Pages) -1- 3/21/19 STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: being duly sworn,deposes and states that he/she is the applicant above named, (print name of individual signing as the applicant) and further states that(s)he is the legal owner of the property to which this application pertains,or that(s)he is the 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. �t1111111/// Sworn to before me this Z Z `���oBF.g 0 Wore me this a a, day of S�� ,20 Z\ ��� �•••••••• • ��` day off'•• O Ste\ 20 Z OF sr L4_ggn,2 ure of Proper ter �sAd�a .Ap 'cant L0 r2 a ss /� • 4�•Ol 4� unly en 19�10� . s •.• o" Casa�eo �.,lG Print Name of Property Owner jQ ••••..pseft Applicant b b�— Notary Public Notary Public This application must be properly completed in its entirety and must include the notarized signature(s)of the legal owner(s)of the subject property, and the applicant of record in the spaces provided. Applications not properly completed in its entirety and/or not properly signed shall be deemed null and void and will be returned to the applicant. _2. 3/21/19 BUILD MENT VIL E OF R OK 938 KING to ET RYE BIR NY 10573 i J U L 3 0 202 1 (914)9 39-5801 w o VILLAGE OF RYE BROOK BUILDING DEPARTMENT AFFIDAVIT OF COMPLIANCE VILLAGE CODE 4216• STORM SEWERS AND SAMTARY 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: '3,�nOre f/'1�.� �� ,residing at,l 6 /�J/Y,4 ���f� � (Print name) (Addres,%+-ltercyou li%c) being duly sworn,deposes and states that(s)he is the applicant above named, and further states that(s)he is the legal owner of the property to which this Affidavit of Compliance pertains at; 1(0 Fwool _.vi AI e COU-4 ,Rye Brook,NY. dob,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. (Si, aturc of properv,0hrncr(. A-e&-!SQ/l G6,d ,111111I1�� Print-�am:ofProltortyOwnert,i) ```,`� ••••ONORM••��.�•• //''' Sworn to before me this �� • �O �',1, �qTF �, day of 5.��- , 20 z p : i�� Pik otaiyPublic) � — I���jO�•• / �7l 11111O1``rr -3- 3/21/19 �yE DR Ccw�4Y�J�J J LC V4 V�`v 40t* annivvoaW VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914) 939-0668 Christopher J.Bradbury www.ryebrook.org TRUSTEES BUILDING&FIRE INSPECTOR Susan R.Epstein Michael J. Izzo Stephanie J. Fischer David M. Heiser Salvatore W.Morlino October 6,2022 Dear Rye Brook Building Permittee, It has come to the attention of the Building Department that your Building Permit has not been closed out in accordance with Village Code and is now expired.All Building Permits have a twelve(12)month lifespan starting from the date of issuance,and the permit expiration date is noted on the front of the permit. Please note that there is a non-waivable Expired Permit Fee of$500.00 now due in connection with your expired permit. Once payment is received,your permit will be reinstated for a period of six(6) months. Please be advised that it is a violation of Village Code to fail to close out a permit,and that a court summons could be issued,and fines may be imposed on the permit holder and/or property owner for failure to apply for and obtain a Certificate of Occupancy(C/O) or Certificate of Compliance(C/C),in accordance with Village Code section 250-10A. Please note that Temporary C/Os&C/Cs are available in accordance with Village Code section 250-10B should you require more time to perform whatever work remains in order to complete your project. Thank you for your attention in this matter,and please feel free to contact this office should you require any further information. Michael J. Izzo Building&Fire Inspector mizzoa.ryebr rook.org /to cc: Steven E. Fews,Assistant Building Inspector Tara A. Orlando,Planning&Zoning Secretary Laura Petersen,Office Assistant O 0 w C I � c N r O a D a(Dr, N l C) r� 00 O TT�v^^vI O 1�1 �z C � v M n Y c 00 Z N6W Yp� LLJ cc IncC �'�,''•�ii N 39d11`C W V Q N J eD J c j Y tb M C+ Building Permit Check List&Zoning Andysis Address: FL (,7v- SBL: Zone,__i_2"2.- : Use: 'Z Const.Type: Other. Submittal Date: (P Z I Revisions Submittal Dates: Applicant A L-V _f A - -__) Nature of Work. 1 h►-T-�-l� /tom lZ rn- ►fir ` zv-7 Dt-a Reviews:zBA:J UN 14 2021 pB: BOT: Other. OK( I-- ( ) FEES:Filing•. 7.S'�, BP: C/O: Legalization: ( ) (_�APP: Dated:_,Notarized: SBL L�4russ 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 Cow.Waiver. Other. ( ) ( ) CODE 753#: Dated: N/A: (vY ( ) HIGH-VOLTAGE ELECTRICAL.Plans: Permit N/A: Other. O O 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. O O 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: A PPROVEn va REQUIRED EXISTING PROPOSED NOTES Date)UN 14 2021 Circle: Fron e 1rQ= SUM $car Main Cov Acts.Cov Ft.H Sb: S .HS : GGFA.' 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' ...'.tea•,::: II#•1/1/II�r, t 4j 1/111/1I1` I e S):�illl/ll#/ll�t # 4 %��11/�11/'�r. If•' �:.tlll/ll#1'I' 4 1�1111/1�1i11:! ('a�ll/l/�/llll� # ���1w4 �, ••S ;t�f�w`�� t•S��•�t . ,(�f��t��j tS•/. ';,.��>r�'w`50�� .�•� ;,��#'„���. t�l�.t ,l�f�r.�l1� t�/. jtr�j����S�,•. !,►••�,•(.����°t.�/r ,'t �.�.. ^' bi "I��' ^ U l t�r ;•'v,r l ro .� i 4p•LL + r, ':t ,ti�1 7 +..' .� t it Y n r VY�t 1 .w ! r rLl'�,,U � ry.6•' ! •. !: %r ���� � �'�'+� {at• �J�yir''SW�i° y� v� r5+,` "��l bAn �'.,�4Nr¢iCiiUi':, .:rtjY�j�; 1 t� j' ' 0:•; .�O �f'k'1 '0 N (qq•O[�,� ad.5 ti5 �O •'O �..55? N O .f7�� �(O '':r; } '��fl �V�Y' �V�'4 Yw�n I•V\1 t1t�V.RgM� I/V il•• tt�r v!! V`��p (/.V� • .. ..0 •�•. '..,cam �'�tq'. NJ+ H `v tY'}y! }+t :i�ryC. :,y,� H� h :ilJ� '�$.i. J r•'' �rJ+� .�y��. y h ,•r, y , vC'Y' ' 1 DATE(MM/DD/YYYY) ACOR" CERTIFICATE OF LIABILITY INSURANCE 11 1 05,'24/2021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Andrea Pena NAME: JOHN M BROWN INSURANCE AGENCY INC PHOIAIC,NE 888Extl -973-0016 aC No): 773 657-2010 750 N FRANKLIN ST STE 208 E-MAIL ADDRESS: andrea@farmerbrown.com INSURERS AFFORDING COVERAGE NAIC# CHICAGO IL 60654-3545 INSURER A: Third Coast Insurance Company INSURED INSURER B: Trisura Specialty Insurance Company Benjamin Rose Build&Design LLC INSURER C: INSURER D: 9 Walworth Ter INSURER E: White Plains NY 10606-2705 1 INSURER F 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 WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER MM DDPOLICY LTR /YYYY) (MM/DDfYYYYI LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE Ix OCCUR PREMISES E.occurrence $ 50,000 MED EXP(Any one person) $ 5,000 A Y N GLSISTC000327121 03/05/2021 03/05/2022 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICYFX]PET LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: I $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT. $ Ea aident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident H L $ X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 3,000,000 B X EXCESS LIAB HCLAIMS-MADE Y N TRXS0003537 03-05-2021 03-05-2022 AGGREGATE $ 3,000,000 DID RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE I I ER ANYPROPRIETOR/PARTNER/EXECUTIVE ❑ E.L.EACH ACCIDENT $ OFFICER/MEMBE R EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Listed as Additional insured: Village of Rye Brook 938 King Street, Rye Brook,NY 10573 CERTIFICATE HOLDER CANCELLATION Village of Rye Brook SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 938 King Street Rye Brook NY 10573 AUTHORIZED REPRESENTATIVE ©19 -2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD NYSIF New York State Insurance Fund WESTCHESTER ONE,44 SOUTH BROADWAY, 10TH FLOOR,WHITE PLAINS,NY 10601-4411 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE 0. n A A A A A 844141981 BENJAMIN ROSE BUILD&DESIGN LLC 9 WALWORTH TER ❑N WHITE PLAINS NY 10606 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER 16 BROOKRIDGE CT BENJAMIN ROSE BUILD&DESIGN LLC VILLAGE OF RYE BROOK 9 WALWORTH TER 938 KING STREET WHITE PLAINS NY 10606 RYE BROOK NY 10573 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE W2510132-0 567695 03/06/2021 TO 03/06/2022 5/25/2021 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2510132-0, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTPS:/MIWW.NYSIF.COM/CERT/CERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THIS POLICY DOES NOT COVER THE SOLE PROPRIETOR, PARTNERS AND/OR MEMBERS OF A LIMITED LIABILITY COMPANY. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. BY CAUSING THIS CERTIFICATE TO BE ISSUED TO THE CERTIFICATE HOLDER, THE POLICYHOLDER UNDERTAKES TO PROVIDE THE CERTIFICATE HOLDER 30 CALENDAR DAYS' NOTICE OF ANY CANCELLATION OF THE POLICY. NEW YORK STATE INSURANCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 127081284 U-26.3