HomeMy WebLinkAboutBP21-167PERMIT # Ale
,+DATE: L� D(P:
SECTION / a 9 r 7 & BLOCKLOT
TYPE OF WORK
10B LOCATION
CONTRALTO
EST.
AID #
COST
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TCO it FEE DATE
INSPECTION RECORD
DATE
FOOTING
FOUNDATION
FRAMING
RGH FRAMING
INSULATION
PLUMBING
RGH PLUMBING
GAS
SPRINKLER
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FINAL
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OTHER APPROVALS
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FF VILLAGR OF RYE BROOD
WESTCHES COUNTY, NP.1w YORK
�� . . ;� NO: 21-176
�?w1A32%
Certificate of (occupaucp
This is to certify that i'V I I r/ ! ��' Lk-mhomT ,'
daer
of, 1► I Q 1 V having duly filed an application on
(1 �i ),er 24 requesting a Certificate of Occupancy for the premises known as,
Trite , Rye Brook,NY, located in a Zoning
District and shown on the most current Tax Map as Section: /& Block: / Lot: z/
and having fu�lllyJ complied withthe requirements of the Building Code and the Zoning Ordinance under Building
Permit No.O{ f u I I , issued 20j2J, 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: Pl-,'-3 C.� � ? 1 / ,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 heig t shak be made,nor shall the building be moved from one location
to another until a permit to accomplish such change has b en b ed th ilding Inspector.
Building Inspector,Village of Rye Brook: Date:
NOV - 2 2021
f- For office use on! .
`� �,, $UILDIN� 1YMATMENT PERMIT# -!&7
VILLAGE OF RYE]BROOK ISSUED:
OCT _ 8 2021 11 KING STREET,RYE BROOK,NE:w YORK 10573 DATE: /p
(914)939-0668,rr
(914�)939-5801 FEE:��1 /I l�— PAuaa
VILLAGE OF RYE BROOK Wook.or
BUILDING DEPARTMENT
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
Address: Z 3 7 T cL' P c / p
Occupancy/Use: I F,4� Parce]ID#: /�-)/p, *7& '/- O Zone: a 6
Owner: W IL-t4 A,aLf r— Address: Z 3'? T�ico <'ld---lcevvl`
P.E./R.A. or Contractor: J>eT,41,4- CL Address: ! V k4 r JLa AWiD r.
�i
Person in responsible charge: /WAce- Address: 11
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:
%d i"-'A,64 being duly sworn,deposes and says that he/she resides at 737 77t1-a' T,"f c,c z uv✓
(Print Name of Applicant) (No.and Street)
in ICE/d �AAX'�r L in the County of IN,,, S Tni ff 17 7A in the State of ,that
(CityiTown/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: $ Z 01 000 '0o ,
for the construction or alteration of: Z � u�i,q
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 4s Sworn to before me this
day of ne ry A ilk , 20—a _ day of 20
Signature of Property Owner Signature of Applicant
Print Name Property ner Print Name of Applicant
Notary Public Notary Public
CHRISTOPHER J.BRADBURY
Notary Public,State of New York
No,01 BR6159985
Qualified in Westchester County
Commission Expires January 29,20 2
�E 4RC��k.
o� �m
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 : ° DATE:
-�4 PERMIT# I ISSUED:� �i2� SE �C � BLOCK: I."
c
LOCATION: I a< U U` Y� 115 CCUPANCY:
❑ VIOLATION NOTED THE WORK IS... ACCEPTED Q 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
QyE BRG.
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1982 BUILDING DEPARTMENT
Q,BUILDING INSPECTOR
/b ASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK
r ❑CODE ENFORCEMENT OFFICER 938 KING STREET • RYE BROOK,NY 10573
(914) 939-0668 FAx (914) 939-5801
www.ryebrook.or
- - - - - - - - -1- - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - -
ADDRESS : \ ` DATE:
rERMIT# � ISSUED: ,- -zti SscT: BLOCK: LOT:
LOCATION: �f� 1 C 4- 7 `""` OCCUPANCY: �L,`)
❑ VIOLATION NOTED THE WORK IS... ACCEPTED ❑ REJECTED/REINSPECTION
❑ SITE INSPECTION REQUIRED
❑ FOOTING L�
❑ FOOTING DRAINAGE
p FOUNDATION
❑ UNDERGROUND PLUMBING NOTES ON INSPECTION:.
ROUGH PLUMBING
p ROUGH FRAMING
❑ INSULATION
❑ NATURAL GAS
❑ L.P. GAS
❑ FUEL TANK
❑ FIRE SPRINKLER
❑ FINAL PLUMBING
❑ CROSS CONNECTION
❑ FINAL
❑ OTHER
(3RC�j�
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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 :— 1 / DATE:
PERMIT#\)L' V ISSUED: ( 1 SECT: BLOCK: LOT:
LOCATION: �1 t� �- 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
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BUIL E MENT
VIL OF RYE K JUL 13 2021
938 KIN FT RYE BROOK,NY 1057 VILLAGE 01= RYE BROOK
(914)9 16 1,4)939-5801 gU�LDING DEPARTMENT
w .or
PLUMBING PERMIT APPLICATION
FOR OFFICE USE ONI,V BP#: u?/`�6 7 PP#: ^I I C7
Approval Date: Permit Fee: S u?'5-P6
Approval Signature: Other:
Disapproved:
(fees are non-refundable)
Application dated, Jvve 1 7 %w-4 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 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,QQState,County and�Local Codes.
1.Address: 'Z 1'7 7—~ �C�tcdAA*— SBL: I cA 7/a—/-c? / Zone:%oi�
2.Proposed Work: RAFTNAuw-f Cerr+►rAtir 7'Va3 T'a '44.4.ray.
3.Property Owner: Address:
Phone#: Cell#: email:
4.Master Plumber: I ` Address: U a r I D7b
Li,.#: iam Phone#: i 7-5 Cell#: q1`� �1`-033 ail: r 5aI VQ t D .GU
Company Name: r t or i Address: cWQM , I ioo
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
1 st Floor
2nd Floor 1
3 Floor
4T Floor
5 Floor
Exterior
5.* List Other Equipment/Provide Details:
(Notarized Signatures Pequired Next 2 Pages)
3/21/19
STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as:
,being duly sworn,deposes and states that heIshe 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 belies;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 920 day of ,20
Signature of Property Owner Signature of Applicant
Print Name of Property Owner Print Name of Applicant
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-
3n 1/19
STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as:
fn/+ccMs- �iEv/��( �C�E✓f✓e(2Ai ,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(a)he is the legal owner of the property to which this application pertains,or that(-@)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 Sworn to before me this I 1
day of 20a_ day of 20 z1
Signature of Property Owner Signature of Applicant
Print Name of Property Owner Print Name of Applicant
Notary Public NotarNia ubii ,State of NeverYork
SHARI MELILLO No.4997135
Notary Public,State of New York Qualified in Westch� -Apcx-County
Term Expires L
No.01 ME616D063
Quafified in Westchester County
ThQD8pphewhckw4nW balpmpftlycon eted 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_
3/21119
BUILD'Nabi�*RTMENT D [E C E N E
VILLA' ,E OF TYL OK
ID
938 KING � > x NY 10573 JUL 13 2 22f
(914)9 ' 39-5801
VILLAGE OF RYE BROOK
BUILDING DEPARTMENT
AFFIDAVIT OF COMPLIANCE
VILLAGE CODE§216 • STORM SEWERS AND SANrrARY SEWERS
THIS AFFIDAVIT MUST BEAR THE NOTARIZED SIGNATURE OF THE LEGAL PROPERTY OWNER AND BE SUBMITTED ALONG
WITH ANY BUILDING OR PLUMING PERMIT APPLICATION. ANY BUILDING OR PLUMING PERMIT APPLICATION
SUBMITTED WITHOUT THIS COMPLETED AND NOTARIZED FORM WILL BE RETURNED TO THE APPLICANT.
STATE OF NEW YORK, COUNTY OF WESTCHESTER ) as:
IAI9u r,a�,� ):4✓c / )X6((d4(A1Aai , residing at, 237 -jrrf C1-eg1 ce",T-
(Print name) (Address where you live)
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;
737 71�<& , Rye Brook, NY.
(Job 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.
(Signature of Property Owner(s))
IAJ IGL
(Print Name of Property Owner(s))
Sworn to before me this
day of ��•, _ , 20�
(Notary Public)
SHARI MELILLO
Notary Public, State of New York
No.01 ME6160063
Qualified in Westchester County
Commission Expires Januanv P9 20 23 _3_
3/21/19
Bull"Permit Check List&Zoning Analysis
Address: c SBL: —
Z..e,. y h —Use: Z,0 Const.Type: Other.
Submittal Date: Revisions Submittal Dates:
Applicant: 't2 F C G-tJ 1 4-A/Z
Nature of Work 1 r.a.j Fi2 c.o n—
Reviews:ZBA: J U L - PB: BOT: Other.
OK
( ( ) FEES:Filing: I BP: C/O: Legalization:
APP: Dated: cV' Notarized SBL ✓Truss I.D. Cross Connection: ✓ H.O.A.:
( } ( ) Scenic Roads: Steep Slopes: Wetlands: Storm Water Review: Street Opening.
( ) ( ) ENVIRO:Long. Short; Fees: N/A.-
SITE PLAN:Topo: Site Protection S/W Mgmt.: Tree Plan: Other.
( } { ) SURVEY:Dated Current: Archival: Sealed.. Unacceptable:
PLANS:Date Stamped ✓ Sealed; Copies��—Electronic. Other.
{v ( ) License: ✓ Workers Comp: - Liability ✓ Camp.Waiver. Other.
( ) ( ) CODE 7S3##: Dated N/A:
( ( } HIGH-VOLTAGE ELECTRICAL:Plans: Permic N/A: Other.
( ) ( } LOW-VOLTAGE ELECTRICAL:Plans: Permit N/A Other.
( } ( } FIRE ALARM/SMOKE DETECTORS:Plans: Permit: H.W.I.C.:—Battery:—Other.
(J, "' ( } 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: APPROVED
REOLJIRED EXISTING PROPOSED NOTES
Am: Date: JUL — 6 2021
l�
Main C
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notes:
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sRv CERTIFICATE OF LIABILITY INSURANCE DATE
(/fll YYYy
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 pollcy(les)must have ADDITIONAL INSURED provlslons 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 lights to the certificate holder in Ileu of such endorsement(s).
PRODUCER CUR 1ACT
NAME: Kathyryn Livingston
Hudson Valley Agents p/c Nn Eat 9457792141 A� .
99 West Main St ADDRESS. kathy@hvagcnts.com
INSURER($)AFFORDING COVERAGE NAIC 9
Walden NY 12586 INSURER A: WESTERN WORLD INSURANCE
INSURED
INSURER a:
Detail C C INSURER C:
158 Joy Rood INSURER D:
INSURER E:
Middlctown NY 1094I 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,
LTR TYPE OF INSURANCE INSO WYD POLICY NUMBER MYlOO LIMITS
x COMMERCIAL GENERAL LIABiLRY EACH OCCURRENCE S 1,000,000
CLAIMS-MADE OCCUR PREMISES(Ea oouunence S 50,000,
MED EXP(Any one person) S 5,000
A NPP8642983 05/13/2021 05/13/2022 PERSONAL aADVINJURY S 1,0011,000
GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000
POLICY JECT ®LOC
PRODUCTS-COMP/OP AGG $ 2,000,000
OTHER: $
AUTOWBILE LIABILITY
ANY AUTO I, addend S
OWNED SCHEDULED BODILY INJURY(Per censor) S
AUTOS ONLY AUTOS BODILY INJURY(Per sadden* S
HIRED NON-OWNED -
AUTOS ONLY AUTOS ONLY aatdenl S
S
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uMastauA LIAR OCCUR EACH OCCURRENCEEXCESS LIAB CWMS-M ADE AGGREGATEDEDR ENTI
ETON SSIERS COM PENSATIONEMPLOYERS'LIABILITY Y/N STATUTE I ER
Y PROPRIETOR/PARTNERIEXECUTNE FICERAUEMBER EXCLUDED? ❑ N 1 A E.L.EACH ACCIDENT $
Mandatory lnNH)I E.L.DISEASE-EA EMPLOYEE S
yna describe under
ESCRIPTION OF OPERATIONS below E.L.OISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,AddBlonal Remarks Schedule,may be attached$more space Is r"ulradl
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
VILLAGE OF RYE BROOK ACCORDANCE WITH THE POLICY PROVISIONS.
938 KING STREET AUTHORIZED REPRESENTATIVE
Jlrrl�`/]rnrr
RYE BROOK NY 10573
0IUS-2015 ACORD CORPORATION. All rights reserved.
ACORD 26(201&W) The ACORD name and logo are registered marks of ACORD
17-04—\h,,I\1
NYSIF
New York State Insurance Fund WESTCHESTER ONE,44 SOUTH BROADWAY, LOTH FLOOR,WHITE PLAINS., NY 10601-4411
1 nysif.com
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
0 0
^^A A A A 462886621
TROY MAAG DBA DETAIL CC
158 MT JOY RD 16
MIDDLETOWN NY 10941
SCAN TO VALIDATE
AND SUBSCRIBE
POLICYHOLDER CERTIFICATE HOLDER
TROY MAAG DBA DETAIL CC VILLAGE OF RYE BROOK
158 MT JOY RD 938 KING STREET
MIDDLETOWN NY 10941 RYE BROOK NY 10573
POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE
W2274 687-9 680923 05/07/2021 TO 05/07/2022 7/4/2021
THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE
FUND UNDER POLICY NO. 2274 687-9, 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:IIWWW.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.
NEW YORK STATE INSURANCE FUND
DIRECTOR,INSURANCE FUND UNDERWRITING
VALIDATION NUMBER: 791287861
U-26.3
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