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HomeMy WebLinkAboutBP21-162PERMIT # SECTION TYPE OF WORK JOB LOCATION OWNERyla� CONTRACTOR EST. COST *,000/CO # TCO # DATE: ExP: 01 .59 BLOCK LOT Qr r %;OLt# 1�7o4l50- V / `/7 cor - 4%x-,%dr;e ( 45)g9#/ 77/S Q F �6`l of s— �i of6 I FEE 4_ �D4DATE__ FEE DATE __- INSPECTION RECORp I DATE INSP FOOTING FOUNDATION FRAMING RGH FRAMING -- INSULATION PLUMBING RGH PLUMBING GAS O SPRINKLER ELECTRIC LOW -VOLT C1 ALARM ED AS BUILT CD FINAL OTHER APPROVALS ARB BOT PB . 'ZBF OTHER THIS BUILDING MUST BE POSTED WIfH A PERMANENT CONSTRUCTION TYPE IDENTIFICATION SIGN; F PRIOR 0 THE ISSUANCE OF A C/O, AS REQUIRED BY NY STATEIAW VILLAGE OF RYE BROOK WESTCHESTI COUNTY, NEW YORK NO: 21-191 (.617,0ertificate of eccupantp This is to certify that Jac- bi n Parmo,,­7 I r�V el l 16_ 1�a rrno.-� of, )Q& &c)C) k_1 A) )( , having duly filed an application on AfQ yemb-eY )5 20 1 requesting a Certificate of Occupancy for the premises known as, C� Rye Brook, NY, located in a Zoning District and shown on the most current Tax Map as Section: � �. Block: Lot: o� , and having fully complied with the requirements of the Building Code and the Zoning Ordinance under Building Permit No.c;� )- 1�0 c�2 , issued 20 ar 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: `.J Qj'7e - (.� /?`J / /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 height sh 11 be made,nor shall the building be moved from one location to another until a permit to accomplish such change has be in o e it ing Inspector. Building Inspector,Village of Rye Brook: 7 Date: DEC — 3 7071 Dv -�F��A � For office use and DID BUILDIN'd UETMENT PERMIT# - jpcl NOV 15 2021 VILLAGE OF RYE BROOK ISSUED: 7— g—a/ 38 KING STREXT,RYE BROOK,NEw YORK 10573 DATE://—/5-41 VILLAGE OF RYE BROOK (914)939-0669 FEE: PAD 0 BUILDING DEPARTMENT wrm2,Kjjbroo1Lor2 APPLICATION FOR CERTIFICATE OF OCCUPANCY,CERTIFICATE OF COMPLIANCE, AND CERTIFICATION OF FINAL COSTS TO BE SUBMITTED ONLY UPON COMPLETION OF ALL WORK, AND PRIOR TO THE FINAL INSPECTION rrrrrrrrrrrrrrrsrrrrrrrrrrrrsr++rsr+r++s+ss+s«+r«•rrrr++++r+++rrrtrtr+rrrrrt+++rrrrrr*rttrrr+trt**rr++*«ar*tt++rrr**r*r*r++*t Address: 2 Parkridge Ct. Rye Brook, NY 10573 Occupancy/Use: Home/Personal Parcel ID#: 135.59-1-2 Zone: 'e f Owner: Jordan and Priscilla Harmon Address: 2 Parkridge Ct. Rye Brook, NY 10573 P.E./R.A. or Contractor: Select Interiors Inc. Address: 15 Cole Drive Armonk, NY10504 Person in responsible charge: Anthony Fascone Address: 15 Cole Drive Armonk, NY10504 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: Jordan & Priscilla Harmon being duly sworn,deposes and says that he/she resides at 2 Parkridge Ct. (Print Name of Applicant) (No.and Street) in Rye Brook ,in the County of Westchester in the state of NY that (City/Town/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 152,390 for the construction or alteration of: Kitchen 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 12th Sworn to before me this 12th day of November , 2027, day of November , 20 21 Signature of Property Owner Signature of Applicant Jordan Scott Harmon Jordan Scott Harmon Print Name of Property Owner � Print Name of Applicant Shae Gamble U "'''�'' Shae Gamble 1�'YnUl1u�11'`p No Public Notary Public as e° r D rr eeR r�` 811212021 t s3u.e D pMR _ cCMMI[iNNI GrIR[c As olsAl MyYmIn IA M[ Notarized online using audio-video communication Notarized online using audio-video communication C BRO O Zm .Fo 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 ryebrook.org - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - ADDRESS: �/ 9 �` `-'ram U DATE: f PERMIT# - ISSUED: t SECT: ` ' BLOCK: ` LOT: Z-- LOCATION: ^\� `fit ,f ,� < [ \ OCCUPANCY:—'? N Q) ❑ 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 �yE BRC�v�,t BUILDING DEPARTMENT ❑BUILDING INSPECTOR ASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK ❑ 938 KING STREET • RYE BROOK CODE ENFORCEMENT OFFICER ,NY 10573 (914) 939-0668 FAx (914) 939-5801 www.nLebrook.org - - - - - - -- -- - - - - - - ---- - INSPECTION REPORT - - - - - - - - - _ - - - - - - - - - ADDRESS : v ) DATE: PERMIT# ISSUED: SECT: BLOCK: LOT: 1 . -)� LOCATION: `f - � 1 1C,o L-9��` OCCUPANCY: -? t ❑ VIOLATION NOTED THE WORK IS... ACCEPTED ❑ REJECTED/REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ROUGH FRAMING l ❑ INSULATION ❑ NATURAL GAS L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL 0 OTHER _ CD fi (71 � N e N N N x a = w x x it ff 4z7 W o q v G $ ; O ., v x � co C' �- op U 0 w Zre c) F/, ONI��/ �j, v Z Z � C m P.- � Q ., z 3 a 16 z F `` o .• A a. z w � o. � oc w a ? w � S 6 6 s s ( 6 6 ( { • yE aR�u D ECEOVE BLT pL .N _�E W!gENT ViL , of RYXE " OK AUG i 1 2021 938 KING ET RYE 13 ,NY 10573 VILLAGE OF (914)9�' 939-5801 BUILDING p RYE �RO01( or - EPARTMENT ELECTRICAL PERMIT APPLICATION Westchester County Master Electricians License Required FOR OFFICE USE ONLY BP#: � Z l t EP#: Approval Date: �- Permit Fee: S 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 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 co7ancep'th all applicable Federal, State,County and Local Codes. 1.Address: ✓t , A 'J SBL: 13,,S9 ��^ c� Zone: -/e�- 2.Property Owner: .�U✓ ' lU Address: Phone#: Cell#: �-�7'(.5��y�y� email: 3.Master Electrician: /�� r i C Address: & K(JI� c Lic.#: >�` Phone#: Cell#: }� � � c� email: EU ,>­c 3C Company Name: DS , ('l U Address: 4.Proposed Electricalf Work/Fixture/Count: .Z, f G h k-, , n, Y C_ / A-L.J r�STATE-OF W1 Y/O�RK,COUNTY OF WESTCBESTER ) as: 'I( k? being duly sworn,deposes and states that he/she is the applicant above named,and does further (print name o 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 R AolrJ C fett1 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 ,20 day 7 20 Signature of Property Owner i a of A lica�� Print Name of Property Owner Print Nam4fof Applicant Notary Public Notary Public 3/21/19 Westchester Rockland Electrical Inspection Services, Inc. Phone: 914-347-3595 DO NOT WRITE HERE-FOR OFFICE USE ONLY 4.3 North Lawn Avenue Fax. 914-347-3596 Elmsford, NY 10523 T BUILDING PERMIT NO. TEMP H DATE I 6 Z CITY OR VILLAGE / ZIP CODE TOWNSHIP COUNTY STREET AND NO.OR ROAD POLE NUMBER BETWEEN WHAT TWO CROSS STREETS IS PREMISES LOCATED? SECTION BLOCK LOT OCCUPAN71{5 NAME BUILDING OCCUPANCY OWNER'S NAME AND ADDRESS HOME TELEPHONE NUMBER 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 j I'NSPECTON OUTSIDE BASEMENT 1"FL. YE ROOK 2'^FL. 3"'FL. 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 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.WRE1S, 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 7 ADDITIONAL I EXPOSED❑ CONCEALED 7 MUST ENTER APPLICANTS IDENTIFICATION NUMBER SERVICE ENTERS BUILDING OVERHEAD E UNDERGROUND C 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 8I� /a �r I �-- - �4v STREET ADDRESS JJ TELEPHONE NO. !7f r r ) UI CITY OR POST OFFICE Zlp CO LICENSE NO.WHEN APPLICABLE I _ 1WESTCHESTER ROCKLAND 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: C&C Electric Jordan & Priscilla Harmon 13 Hull Rd CT, Danbury 06811 Located at:2 Parkridge Ct Rye Brook, NY 10573 Certificate Number: 1031448 Section: 135.59 Block: 1 Lot:2 BDC: Permit Number: EP:21-198-BP;21-162 A visual inspection of the electrical system at this premise described as a Residential occupancy,wherein the premises electrical system consisting of electrical devices and wiring,described below,located inion the premises at: 2 Parkridge Ct Rye Brook,NY 10573 Basement 125 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 11/15/21 Name Type Quantity Fixture-Strip LED 11'undercabinet 1 Receptacle GFCI ------- 3 Fixtures Pendant ------- 3 Dishwasher ------- 1 Disposal ------- 1 Microwave ------- 1 Wine Chiller ------- 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. i • ■ i N N � ar n lift , r14 ,,, O ++ z cp $ _ sic CIO a � Z � = a 3If,00 c w Ca' o W qt u � C7.,00 z Q � E a � O106Elm ■ �'` V o c Q zs Q U ti _ W N ■. bn� f� Li Y rtn a ECEWE BUILi.EPA,RTMENT VIL `F E OF RYE OOK JUL 2 9 2021 938 KING ET RYE B11 ,NY 10573 VILLAGE OF RYE BROOK (914)93}'.r _._1Ax 939-5801 BUILDING DEPARTMENT www �io�.org PLUMBING PERMIT APPLICATION R FOR OFFICE USE ONLY BP#: �I-I c - PP#: f r Approval Date: Permit Fee:$-V I. Vt.I Approval Signature: Otber: Disapproved: (fees are non-retoodable) Application dated, �1'jc�l is hereby,ma a to Building inspector of the Village of Rye Brook NY,for the issuance of a Permit to install and/ol rcnxke Plumbing as per detailed statement described below.The applicant&property owner,by signing this document agree that said plumbing work will be in conformmartce with all applicable Federal,State,County and Local Codes. 1.Address: vFT— SBL:jj5f S9- ol_ _ Zane: 2.Proposed Work: INS �s l�c {.c 5��. f �G F l'i 3. U14- 1 G61-o le'X e ,. /Pep-o vty"'j ali - —SiS Uc- 3.Property Owner: 0,— a,-7 ♦ a r'a Address:'r Phone#: Cell #: sP14--75Q-`��7 7 email: 4.Master Pl umber:Mr6C'r C / Address: G G+-► tJe�. �c (`� (j�{ Lic.#: IqZ-'Y Phone# Cell#: L G/ entail: mb► (Y)Cc �rs ties / � p [ Company Name: \s,y _ F'n l�m t "r+1 SL1 "C C h Address:a {d uc INDICATE FIXTURES& LINES TO BE INSTALLED AS PER THE FOLLOWING SCHEDULE: Location Water Urinals Drinking Sinks Showers Bath Laundry Domestic Fire Sanitary Naturall Other* Total Closets Fountains Tubs Tubs Service Service Sewer LP Gas Basement 1st Floor 2nd Floor 3"'Floor 411 Floor Sm Floor F.xteriox S.*.List Other Equipment/Provide Details: (Notarized Signatures Required Next 2 Pages) -1- 3/21/19 4 STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: ,being duly swan,deposes and states that heJshe is the applicant above named, {print namc of individual signing as the applicant) and fiu1her 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 clue 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 "2 6 Swom to before me this Z Z N� day of J 20 '2-- _ T day of -�U 20_L__ Slbmwre—o_lirroperty Owner Signature of Applicant ris6 vtmoyv Jordaty �6,rrt' 0VV � 6GNU Print Name Pr arty Owner acne of Appli NotaryfRuNic Naq Publi Philip Gaspadno Notary Public,State of New York Reg,No,o1GA8388126 ou lMied In Westchester County This application must be properly completed in its entirety and must Inc Iud�r0W8'q1WAW?M(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. TERESA MARIE BARONE NOTARY PUBLIC-STATE OF NEW YORK No.01 BA6252564 Qualified in Westchester County My Commission Expires 12-12-20 2-3 -2- 3/21/19 $UILD�- RTMENT D ECE V E VILL E OF R4*MK JUL � 9 202� 938 K>�vG �7r RYA BRVUK,NY 10573 1 139-5801 VILLAGE OF RYE BROOK ol,v' BUILDING DEPARTMENT AFFIDAVIT OF COMPLIANCE VLLLAGE CODE&21E•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 YOM COUNTY OF WESTCHESTER ) as: 30(doW $ P(tSU I1g 4r4 V residing at, 4 Rgdc Rt(Ac�c - Prini name) (Address where you five) being duly sworn, deposes and states that (s)he is the applicant above named,and fiirther states that(s)he is the legal owner of the property to which this Affidavit of Compliance pertains at; L c r Q/C4 C a u rj'�` , Rye Brook, NY. IJoh Address) Further that all statements contained herein are true, and that to the best of his/her knowledge and belies; 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. C70S,gnawreol tiurrlsll {IsUII&I �6rrncvv Joy-d0t/Armovt/ {Print Name of PrWertyOwnerls)) Sworn to before me this TERESA MARIE BARONS day U 2al NOTARY PUBLIC•STATE OF NEW YORK No.01gA62525e4 Qualified in Westchester County (Nouiry Public) My Commission Expires 12-12-20?3 3/21/19 Building Permit Check List&Zoning Analysis Address. —��i �4R-- �7j _t — SBL• Zone.• —12 Use: t C-D- Cont.Type: Other. Submittal Date: (O Z Revisions Submittal Dates: Applicant L'`t D+`� I Nature of Work: l 1 � a1L_ � Reviews:ZBA: J U L PB: BOT: Other. NEED OK ( ( ) FEES:Filing: 7 S9V• ' C/O: Legalization: ( ) (,), APP: Dated: ✓ Notarized SBI_ ✓Truss I.D. Cross Connection: ✓ H.O.A.: ( ) ( ) Scenic Roads: Steep Slopes: Wetlands: Storm Water Review: Street Opening. ( ) ( ) ENVIRO: Long Shore Fees: N/A: ( ) ( ) SITE PLAN:Topo: Site Protection: S/W Mgmt.: Tree Plan: Other: ( ) ( ) SURVEY:Dated Current: Archival:- Sealed Unacceptable: ( ) ( PLANS:Date tamped; ✓ Sealed. ✓Copies:�— Electronic. Other. ( ( ) License: Workers Comp: ✓ Liability: ,` Comp.Waiver. Other. O O 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. 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: REOUIRED EXLSI'ING PROPOSED APPROVED Ann: .,_w JUL - 2 2021 Ste: MainC Ft.H/Sb: Sd.H/Sb: -GFA: Tot Imp Ft. HcLokista>ies: notes: ««�)1 .. ,.�.. "tia., s 3- •,;-�Z.B,�-.FyS.-d; + r..- � �.. ty ����rr (b).1 _ w O O CDEL P CO =♦ate' �: "ten� ^� y � C 4-t -� • ''� - / F' C 42 S r .� ACD Cd LQ ca LU ME L qk t(o)) �---► �y LIJ W z CA Lo LD W >•(i.+ O A kn'�' -'G�+� /fr 5 Oii is %fir cd �" O ' CV tAIR O ur) N U N may. CU c �-`*` )�)i.•••' � ��+(+++(+'` .ag g- 4�¢�'�s�.i�'11+1(��� ��- -'AN +�jl =r_w • p, w yr Sr' 1 A`01R" CERTIFICATE OF LIABILITY INSURANCE 70670/2021 MIODIVYYY) 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 Aaron Epstein NAME: Westrock Insurance Agency AHCNNo Ext; (845)638-2300 AC No: (845)638-6222 151 North Main Street E-MAIL Aaron@westrockinsurance.com ADDRESS: Suite 204 INSURER(S)AFFORDING COVERAGE NAIC# New City NY 10956 INSURER A: Falls Lake National Insurance Company 31925 INSURED INSURER B Select Interiors Corp. INSURER C 15 Cole Dr INSURER D INSURER E Armonk NY 10504-3004 INSURER F: COVERAGES CERTIFICATE NUMBER: 2021-2022 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. TR TYPE OF INSURANCE IN SD WVD POLICY NUMBER �MWDDY EFF IP�DY EXP LIMITS X COMMERCIAL GEN ERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE N OCCUR PREMISES Ea occurrence $ 100.000 MED EXP(Any one person) $ 5,000 A Y CPP120405412 01/02/2021 01/02/2022 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 X POLICY PRO 2,OOD,000 JECT LOC PRODUCTS-COMPIOPAGG $ OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE S AUTOS ONLY AUTOS ONLY APer accident X UMBRELLA LIAB OCCUR EACH OCCURRENCE s 5,000,000 X A EXCESS LIAR CLAIMS-MADE Y CUP 1206102 10 02/23/2021 01/02/2022 AGGREGATE $ 5,000.000 DIED I X1 RETENTION S 10,000 S WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STAT E UTE ER ANY PROPRIETORIPARTNERIEXECUTIVE ❑ NIA EL EACH ACCIDENT $ OFFICERMIEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached it more space Is required) Additional Insured Village of Ryebrook 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 Street AUTHORIZED REPRESENTATIVE Ryebrook NY 10573 � Lr ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD NEW Yo K Workers' CERTIFICATE OF STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE BOarC� 1a. Legal Name&Address of Insured(use street address only) 1b. Business Telephone Number of Insured Select Interiors Corp. (845)494-7715 15 Cole Dr Armonk NY 105043004 1c. NYS Unemployment Insurance Employer Registration Number of Insured Work Location of Insured (Only required if coverage is specifically limited to 1d. Federal Employer Identification Number of Insured or Social Security certain locations in New York State, i.e., a Wrap-Up Policy) Number 831155434 2. Name and Address of Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) StarStone National Insurance Company Village of Ryebrook 938 King Street Ryebrook NY 10573 3b.Policy Number of Entity Listed in Box 1a" T20201561 3c.Policy effective period 11/03/2020 to 11/03/2021 3d.The Proprietor,Partners or Executive Officers are included. (Only check box if all partners/officers Included) Q all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box"S'insures the business referenced above in box 1 a"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: Avi Epstein (Print name of authorized representative or licensed agent of insurance carrier) Approved by: 06/30/2021 (Signature) (Date) Title: Principal Telephone Number of authorized representative or licensed agent of insurance carrier: 845-638-2300 Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-105.2. Insurance brokers are NOT authorized to issue it. C-105.2 (9-17) www.wcb.ny.gov