HomeMy WebLinkAboutBP21-156PERMIT # vi� /��p DAM CRC 1 EXP:
SECTION , �-=- BLOCKS�^�' LOT_, of
TYPE OF WORK _ .�i. Agoo/ n j< ✓7f oVa2 90!a
JOB LOCATION _-13/ o So 4S% 1&%lnbl I..�o, cry o�
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INSPECTION RECQRD
DATE
FOOTING
FOUNDATION
FRAMING
RGH FRAMING
INSULATION /
PLUMBING EE
RGH PLUMBING
GAS O
SPRINKLER
ELECTRIC C
LOW -VOLT C�
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AS BUILT ElFINAL
INSP
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OTHER
VILLAGE OF RYE BROOK
WESTCHESTyg COUNTY, NEw YORK
21-181
Certificate of Orrupaurp
This is to certify that J f
of, Al"le, .Q t' Oe /k 7 having duly filed an application on
0-:k)L)er cZ��. 20 J I requesting a Certificate of Occupancy for the premises known as,
/,3 jf BrLtSh 1 16 V V lam' �/� , Rye Brook,NY,located in a RA D Zoning
District and shown on the most current Tax Map as Section: J 6A. / W Block: / Lot: /2 4? ,
and having fully complied with the requirements of the Building Code and the Zoning Ordinance under Building
Permit No. , issued (0 >2 20 e /, such authority and permission is hereby granted
to the propertti owner to lawfully occupy or use said premises or building or part thereof listed under the New York
State Use Classification of: R`6 Y]'r- — F-t-r� l+ , for the following purposes:
60 J)� ro0)-0 Pena leja ham
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 beqn obtained from-the- uilding Inspector.
Building Inspector,Village of Rye Brook:
NOV 1 5 2021
D ` BUILDING DEPARTMENT For office use onI r:
PERMIT# f j��(�
�y VILLAGE OF RYE BROOK ISSUED:
OCT
2 2 2021 LS KING STREET,RYE BROOK,NEW YORK 10573 DATE:
(914)939-0668 FEE: //o PAID
ViL+A DK www.ryebrook-org
EUIL_DIN'— f'E-RAR T%1ENIT
.DPPLICATION 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;
Occupanc�y�/`Use: � Parcel ID#: �� / �'' �1 Zone:
Owner; V V�rld `�� (l�j'I CU-7 Address: Al P.E./R.A.or Contractor: `,P V'InH e l ITS 4 Address: ,✓J
Person in responsible charge: Ir V� l elMO-17 Address: 131 YG`S'h 146/1dc�
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:
s •r av-\ being duly sworn,deposes and says that he/she resides at
(Print 'ante of Applicant) (No.and Street
in LK � ,in the County of in the State of� ,that
(C'ity.^Tou at 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:S -A q q 3
for the construction or alteration of: 5 a4`h V-0zn>
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 structurelwork 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 orgtructure until a Certificate of Occupancy orCertiftcate of Compliance shall have been duly issued by the Building .
Inspector as per§250-1 Q.A.of the Code of the Village of Rye Brook.
Sworn to before me this Sworn to before me this
day of , 20� day of � -'t�' 20
Signature of Prope caner Signature of Appr t
! Imp f4.yv\
Print Namc of Property Owne Print Name of App ica
No ary Public rotary Public
SHERI S.pAOERNAC,4T SHIERI S.PADERNACHT
NOTARY PUBLIC,STATE Of NEW YO"
No.07 PA6035809 NOTARY PUBLIC.STATE Of NEW YOPA
ouslified in WestcttesterCOUnIV No.01PA5035809
My Commission Expires No%14._:&0L Z Oosllfied in Westchester
'My Commission Expires Noti 14,ZQFwz
1982 BUILDING DEPARTMENT
❑BUILDING INSPECTOR
ASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK
( o CODE ENFORCEMENT OFFICER 938 RING STREET • RYE BROOK,NY 10573
(914) 939-0668 FAX (914) 939-5801
www.Uebrook.org
- - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - -- - -
ADDRESS: ;� � DATE:
PERMIT# ISSUED:I SECT: BLOCK: 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
❑ ROUGH FRAMING
❑ INSULATION
❑ NATURAL GAS
❑ L.P. GAS
❑ FUEL TANK
❑ FIRE SPRINKLER
❑ FINAL PLUMBING
❑ CROSS CONNECTION -
FT,
❑ OTHER
�E BRC��.
a`` tim
BUILDING DEPARTMENT
❑BUILDING INSPECTOR
SISTANT 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 : V S DATE'
1 r
PERMIT` ISSUED: SECT: BLOCK: LOT:
LOCATION: OCCUPANCY:
❑ VIOLATION NOTED THE WORK IS... ACCEPTED El REJECTED/ REINSPECTION
[I SITEINSPECTION REQUIRED
❑ FOOTING
❑ FOOTING DRAINAGE
❑ FOUNDATION
❑ UNDERGROUND PLUMBING NOTES ON INSPECTION:
OUCH PLUMBING
❑ ROUGH FRAMING
❑ INSULATION
❑ NATURAL GAS
❑ L.P.GAS
❑ FUEL TANK
❑ FIRE SPRINKLER
❑ FINAL PLUMBING
❑ CROSS CONNECTION
❑ FINAL
❑ OTHER
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Bua. E� MENT MAy 2 5 2021
VIL E OF RYE 'OOK
938 KIN 1rTRYE B ' -Y NY 10573 VILLAGE OF RYE BROOK
(914)9 939-58Q1 � BUILDING DEPARTMENT
--
.ot
PLUMBING PERMIT APPLICATION � r
FOR OFFICE USE ONLI BP#: PP#: C>") V
MAY 2 7 2021
Approval Date: Permit Fee: S IQI
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 , w 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: 13) i4odovy C rt5e.4 SBL: / ,71 -l-la9 Zone: 4D
2.Proposed Work: I n e54 e 11 5 h ow 4,1 b o d y o t1 d N n l (l n � 4 o%r c-r+
3.Property Owner: �Tt � ��i lh ort Address: 131 614,) } N o l l oW _C It 5 trti
Phone#: Cell#: Y 14" 5 ola� -4 9 4 D-- email: H c_�,yr\6n � Q lrtcx t I .cC)g
4.Master Plumber: rj ohl c I G tr i e_w Address: 1 1 5 W a 11 5�r t ci vo l hat E n� 105�5
u
Lic.#: r 9_5 Phone 4: } 14 - C66- ) I ), Cell#: 0A03- 4;4$ - Ot74 email: r]Qt. —�r *4 P� q66 Fh4mbirj.cor
Company Name: �1 w�eM�� S C I W i cQ!) Address: D-5 V o l) 5�1 e-t4 V o l h o iJ 4 'N I I OS 9 9
INDICATE FIXTURES&LINES TO BE INSTALLED AS PER THE FOLLOWING SCHEDULE:
Location Water Urinals Drinking Sinks Showers Bath Laundry Domestic Fire Sanitary NaturaV Other* Total
Closets Fountains Tubs Tubs Service Service Sewer LP Gas
Basement
1 st Floor
Ind Floor ,
3"'Floor
4'h Floor
S 'Floor
Exterior
5.* List Other Equipment/Provide Details:
(Notarized Signatures Required Next 2 Pages)
312t119
STATE OF W YORK,COUNTY OF WESTCHESTER ) as:
LC[V&C 0 ,being duly sworn,deposes and states that he/she is the applicant above named,
rin name of individual signing as the applicant)
and further states that(s)he is the legal owner ofthe 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 ofthe 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 20 21
Signature of Property Owner Signature of-Applicant
0"� '4,"1 - .-lC
!Tint Name of Property Owner 1hini Name of Applicant
dftw—V
CHERYL A.ZASTENCHIK Z +
Notary Public Notary Public state of Mew York LaryPuNic
No.oiZA6098466
Qualified In Putna�,rt OuntY
My Commission Expires Y
This application must be properly completed in its entirety and must include the notarized signature(s)of
the legal owner(s)ofthe subject property, and the applicant ofrecord 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
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 ae the appliuini)
and further states that(s)he is the legal owner of the property to which this application pertains,or that(s)he is the
fbr 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 kefore me this ! Sworn to before me this
day of IV\ 20 � day of ,20
] 1,
S -�' J�—
Signature of ProartyOwner Signature of Applicant
t�C'Y�� A�F.a. Y)a
Print Name of Property Owner Print Name of Applicant
Nptary �blic 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.
GeM dine A.Tolan
IKWPUBUC,STATE of NEW YOAx
Re&Mdn No.01TO6291406
Qrierdili�ietrCetsryCetifigtt 9o1>,tlt>I Tetfwrt
QatmirsiQa Expires October 15,24
-2-
3/21/14
BUILDING DEPARTMENT P
VILLAGE OF RYE BROOK MAY 2 5 202i E 0 1
938 KING S`rREE'r RYE BROOK,NY 10573
(914)939-0668 FAx(914)939-5801 � VILLAGE OF RYE BROOK
BUILDING DEPARTMENT
rs.vwxyebrook.orL
##wwww#*wf*wfwr#-*ww*ww#www########few*wwwwwwww#*#tww�w*�►*wwwwwww#w#w+w#*#e#######fwww##**+:wwr*wwwwwwww
AFFIDAVIT OF COMPLIANCE
VILLAGE LODE §216- STORM SEWFRS 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 YOM COUNTY OF WESTCHESTER ) as:
residing at, 5 Cjl .
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,
Rye Brook, 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.
(5iunatmv uI 1'i,.i tt ��1��n 1��1I
Sworn to before me this
day of 2001
CoWdine A.Tolan
ypUUJC,STATE OF NEW YORK 3
Registration No.01 T06291406
ddialle+II I CW&Cemfirur9edsNnYadCaartj
Commission Expires QCtDkf 15,20d 1 3/2 i/19
{� Buildin Perrzut Check List&Zonm' Anal sis
Address: ` ! 'x SBL: -~ r
Zone: V.lJ.r / Use: 2 Const.Type: N9 Other.
Submittal D 1 Revisions Submittal Dates:
Applicant: q1 # V
Nature of Work VC,-10 C-1
Reviews:ZBA: P& BOT• Other:
�2_.
FEES:Filing: -L<ual� BP: C/O: Legalization:
APP: Dated:,L.,—Notarized: ✓SBL:1_— 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
Electronic;—Other
License::Date Workers Comp Seale�Copies: mp Waiver Other.
( ) ( ) CODE 7S3#: Dated: N/A:
( ) ( ) HIGH-VOLTAGE ELECTRICAL.Plans: Permit N/A Other:
( ) ( ) LOW-VOLTAGE ELECTRICAL:Plans: Permit N/A: Other:
( yY ( ) PRE 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
REQ PROPOSED NOTES
Arm... date:.
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AC" DATE IMWDDIYYYY)
II CERTIFICATE OF LIABILITY INSURANCE F621'2021
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(ins)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
NAME: Jon Belinkie
Health Insurance Specialists FAX
,vc No E:t: 3015900006 (Arc,No): 3015900661
PO Box 5743 ADDRESS: jbelinkie(_q—;his-inc.com
INSURER(S)AFFORDING COVERAGE_ _ NAIC R
Derwood MD 20855 INSURER A: PENNSYLVANIA NATL M17 CAS INS CO 14990
INSURED INSURER B: PENN NATL SECURITY INS CO 32441
Remodel USA,Inc. INSURER C: CHESAPEAKE E.LLPLOYERS INS CO 11039
605 Hampton Park Blvd. INSURER D:
INSURER E
Capitol Heights MD 20743 INSURER F
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS 1S TO CERTIFYTHAT 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.
LTR TYPE OF INSURANCE IPOLICY EFF
NSD WVD POLICY NUMBER (MMIDD1YYYY) (MIN ODYNEY ) LIMITS
x COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE 7 OCCUR PREMISES(Ea occurrence $ 500,000
MEO EXP(Any one person) S 5,060
A CL9 0768820 01/01/2021 01/01/2022 PERSONAI&ADV INJURY S 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
POLICY JET ❑LOC PRODUCTS-COMPIOP AGG $ 2,000,000
OTHER $
AUTOMOBILE LL&B1LITY
Ea accident S 1,000,000
ANY AUTO BODILY INJURY(Per person) S
B OWNED SCHEDULED
AUTOS ONLY AUTOS AX9 0768820 01/01/2021 01/0112022 BODILY INJURY(Par accident) S
HIRED NON-OWNED AMAGE $ -
AUTOS ONLY AUTOS ONLY Per accldent
S
X UMBRELLA UAB OCCUR
EACH OCCURRENCE S 2,000,000
A EXCESS LIAB CLAIMS-MADE 1JL9 0768$20 0110112021 01/01(2022 AGGREGATE S
DED I I RETENTION$ S.
WORKERS COMPENSATION PER T-UTFF
AND EMPLOYERS'LIABILITY Y r N STATUTE ER
ANY PROPRIETORlPARTNERIF_XECUTIVE E.L.EACH ACCIDENT $ 500,000
C OFFICERIMEMBEREXCLUDED? ❑ NIA 8003679 09/11/2020 09/11/2021
Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S 500,000
f yes,describe under
ESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT S 500,000
Workers Compensation Each Accident 500,000
C Virginia J- WC9I5458200 9 11'2020 09'11/2021 Disease EA Employee 500,000
Disease Policy Limit 500,000
DESCRIPTION OF OPERATIONS f LOCATMNS r VEHICLES (ACORD 101,Addltlonal Remarks Schedule,maybe attached If more space Is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
The Village of Rye Brook ACCORDANCE WITH THE POLICY PROVISIONS,
938 King Street AUTHORIZED REPRESENTATIVE
Rye Brook NY 10573
OO 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD
PORK Workers' CERTIFICATE OF
�e Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE
Board
1a.Legal Name&Address of Insured(use street address only) 1b. Business Telephone Number of Insured
Remodel USA,Inc. 301-333-6000
605 Hampton Park Blvd.
Capitol Heights,120743 1 c. NYS Unemployment Insurance Employer Registration Number of
Insured
Work Location of Insured(Only required if coverage is specifically limited to
certain locations in New York State,i.e.,a Wrap-Up Policy) 1 Federal Employer Identification Number of Insured or Social Security
Number
52-2209255
2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier
(Entity Being Listed as the Certificate Holder)
Zurich American Insurance Company
The Village of Rye Brook 3b. Policy Number of Entity Listed in Box"1a"
938 King Street
Rye Brook, NY 10573 we s15a5s2-oo
3c. Poiicy effective period
09/1112020 to 09/11/2021
3d.The Proprietor, Partners or Executive Officers are
❑ included.(Only check box if all partners/officers indLided)
X❑ all excluded or certain partners/officers excluded.
This certifies that the insurance carrier indicated above in box"T'insures the business referenced above in box"la"for workers'
compensation under the New York State Workers'Compensation Law. (To use this form, New York(NY)must be listed under Item 3A
on the INFORMATION PAGE of the workers'compensation insurance policy). The Insurance Carrier or its licensed agent will send
this Certificate of Insurance to the entity listed above as the certificate holder in box"2".
The insurance carrier must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy is canceled
due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or
eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail.)Otherwise,this
Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent,or until the policy
expiration date listed in box"3c",whichever is earlier.
This certificate is issued as a matter of information only and confers no rights upon the certificate holder. This certificate does not amend,
extend or alter the coverage afforded by the policy listed, nor does it confer any rights or responsibilities beyond those contained in the
referenced policy.
This certificate may be used as evidence of a Workers'Compensation contract of insurance only while the underlying policy is in effect.
Please Note: Upon cancellation of the workers' compensation policy indicated on this form, if the business continues to be
named on a permit, license or contract issued by a certificate holder,the business must provide that certificate holder with a
new Certificate of Workers' Compensation Coverage or other authorized proof that the business is complying with the
mandatory coverage requirements of the New York State Workers' Compensation Law,
Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced
above and that the named insured has the coverage as depicted on this form.
Approved by: Jon Befinkie
(Print name of authorized representative or licensed agent of insurance carrier)
Approved by: Qt y 06/28/2021
(Signature) (Date)
6,1
Title: Owner
Telephone Number of authorized representative or licensed agent of insurance carrier: 301-590-0a05
Please Note'. Only insurance carriers and their licensed agents are authorized to issue Form C-105.2. Insurance broken are[W
authorized to issue it.
C-105.2 (9-17) www.wcb.ny.gov