HomeMy WebLinkAboutBP21-172PERMIT #6i°QI s 17cA DATE: �� d EXP: as
SECTION 135, 7,T BLOCK_ _ LOT ,O
TYPE OF WORK �CaCP�'Je/!f" orb �PC/�! Q/ /�(/5��5 �����r�� �°���✓e/ �4I�'
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CONTRALTO
qsw/c0 # �' �d FEES a DATE
TCO # FEE DATE_
INSPECTION RECORD
DATE
FOOTING
FOUNDATION
FRAMING
RGH FRAMING
INSULATION
PLUMBING C]
RGH PLUMBING
GAS 0
SPRINKLER
ELECTRIC 0
LOW -VOLT 0
ALARM cl
AS BUILT CO
FINAL
INSP
OTHER APPROVALS
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ARB �ne �Co a0�/
BOT
PB
ZBA
OTHER
VILLAGIR�bF RYE BROOK
WESTCHESTER COUNTY, NEW YORK
No: 22-106
Certificate of ®ccupaucp
This is to certify that Dan r e) le �v-eewao
of, P)(e byoC)k. N y having duly filed an application on
20 requesting a Certificate of Occupancy for the premises known as,
1� V\ d)ona Avenut. , Rye Brook,NY, located in a_lb-Zoning
District and shown on the most current Tax Map as Section: 136,7 5 Block: 1 Lot: Lo 9 ,
and having fully complied with the requirements
/Iof,the Building Code and the Zoning Ordinance under Building
O 7
Permit No. I - = , issued � ) (4 20 a2 1, 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 following
New York State Classifications, Use: /�-� D�e' / Construction:
for the following purposes: C deC16
( h-ri Y s
ver w
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 qiade,nor shall the building be moved from one location
to another until a permit to accomplish such change has been obtli e om the nspector.
Building Inspector,Village of Rye Brook: ate: JUL 2 5 2022
v
For office use onl :
3D BUILD DEPARTMENT PERmrr
JUL — 1 2022 VILq
OF RYE B K ISSUED: gyp— — /
938 KING STREEYE BROOK,N YORK 10573 DATE: —/--a a-
VILLAGE OF RYE BROOK (914)9 (91 939-5801 FEE: -- PAll X
BUILDING DEPARTMENT ore
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
r«rrrtwssrwrsssrsrrssststtsssstsswsssssswssrssstsssrwssswssrssswsrsrsststswswsrswswssssssttwswts►►rrrrrrrtsswswssrrssrsssssss
Address: 1 W o G U I Cart Ck I�V�rty�
Occupancy/Use: Z F,4A Parcel ID#: 13 5•lS — I—bq Zone:
Owner: 0Cknte142 FVW_CMQrl Address: '18 %400pi,Qnn A•y-enve .
P.E./R.A.or Contractor: ' Address:
Person in responsible charge: Address:
Application is hereby made and submitted to the Building Inspector of the Village of Rye Brook for the issuance ofa 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:
narli P 1%k F 2Qo rn��n being duly sworn,deposes and says that he/she resides at -1 b W UU u i c]n c7 A�V=Z
(Print Name of Applicant) (No.and Street)
in smoo1- ,in the County of we%A c h P s A-e i2. in the State of J�X that
(Cityfrown/Village)
he/she has supervised the work at the location indicated above,and that the actual total cost ofthe 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:$ 1 , 500 ,
for the construction or alteration of: (Ro or- vdnzCh eA n d R.O►a iin a: ► CW 20.0 a IZ W ojt kW
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.
Swom to before me this (<j Sworn to before me this AN
day of No, , 20�L day of , 2024
Sign fPropertyOwner �gnaiuef Applicant
`�ar,�ell�' rn�r L_)CXnVe1U� rmCA�-�
Print Name of Pro Owner Print Name of licant
Nota Pub i Notary Pu
Lynette B. Coe
Notary Public. St<ae of New York Lynette B. Coe
Igo. (1:000IJSSEiy1/>9
l�unlified in l estelrester•Count Notary Public. State of New or
No. 0:C06I 9666ii
C MIlLiEsiUtr Expires Jail- U`''2U Qunlif'iccl in Westchester County
Coranrissiun Expires Jan. U5,2U. f
qyE BRC��.
�0 1 �
'982 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� C--1 4 DATE,
PERMIT# 1 ISSUED: l ' LCT: BLOCK: ' Lo4l--
LOCATION: 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.• Building Permit Check List&Zoning Analysis
< <Address: Z.4.3, SBL
Zone:IZZ-�7 IUse: Z( o Const.Type Other. A - t Z AZT7 C,
Submittal Date: l Cl Z t Revisions Submittal Dates:
Applicant: 1-t=F�+
Nature of Work: t]C- -!::,6C t c9N
Reviews: 1 PB• BOT• Other.
OK m
( ( ) FEES:Filing. 7S- BP: too —�"' C/o. Legalization: 7.S�J
( ) (_�A P: Dated: ✓ Notarized:_j,�-tBL: ✓fines I.D. Cross Connection: --"' H.O.A.:
( ) ( ) Scenic Roads: Steep Slopes: Wetlands: Stone Water Review: Street Opening.
( ) ( ) ENVIRO:Long. Short Fees: N/A:
( ) ( ) SITE PLAN:Topo: Site Protection: S/W Mgmn: Tree Plan: Other.
( ) ( ) SURVEY:Dated Current Archival• Sealed Unacceptable:
( ) ( ) PLANS:Date Stamped: Sealed Copies: Electronic. Other.
(� ( ) License: Workers Comp: Liability Comp.Waiver: Other.
( ) ( ) CODE 753#: Dated N/A:
( ) ( ) HIGH-VOLTAGE ELECTRICAL:Plans: Permit N/A: Other.
( ) ( ) LOW-VOLTAGE ELECTRICAL:Plans: Permit N/A: Other.
( ) ( ) FIRE ALARM/SMOKE DETECTORS:Plans: Permit H.W.I.C.:_Battery:_Other.
( ) ( ) PLUMBING:Plans: Permit Nat.Gas: LP Gas: N/A/: Other.
( ) ( ) FIRE SUPPRESSION:Plans: Permit N/A Other.
( ) ( ) H.V.A.C.: Plans: Permit N/A Other.
( ) ( ) FUEL TANK:Plans: Permit Fuel Type: Other.
( ) ( ) 2020 NY State ECCC: N/A: Other:
( ) ( ) Final Survey Final Topo: RA/PE Sign-off Letter. As-Built Plans: Other.
( ) ( ) BP DENIAL LETTER: C/O DENIAL LETTER: Other.
( ) ( ) Other.
(J�ARB mtg.date: S IQ Z l approval• notes:
( )ZBA mtg. date: approvaL• notes:
( )PB mrg.date: approval• notes: APPROVED
REQUIRED EXIMNG PROPOSED NOTES JUN 1 7 2021
Ate; Date:
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, N.
BUILDING DEPARTMENT D E C E N E
VILLAGE OF RYE BROOK
938 KING STREET RYE BROOK,NY 10573 APR - 9 2021
(914)939-0668Af
(914)939-5801
00korg VILLAGE OF RYE BROOK
BUILDING DEPARTMENT
ARCHITECTURAL REVIEW BOARD CHECK LIST FOR APPLICANTS
This form must be completed and signed by the applicant of record and a copy shall be
submitted to the Building Department prior to attending the ARB meeting. Applicants
failing to submit a copy of this check list will be removed from the ARB agenda.
Job Address: 1� Wocdlar►d AJenve Date of Submission:
Parcel ID#: 01a A I Lo f (.9 ZoneL�
Proposed Improvement(Describe in detail): APPLICANT CHECK LIST:
MUST BE COMPLETED BY THE APPLICANT
. 4- The following items must be submitted to the Building
(Z4ijj — A,,,,-e- Department by the applicant-no exceptions.
(�rQSe �s}�cr2g a gel f;t..-.- We"AT 66Qd,,g 1. ( 4"C'ompleted Application
2. ( )Two(2)sets of sealed plans. (one full size{maximum
Property Owner: t Uor e►w ]EQkg.mnr-, allowable plan size=36"x 42")and one 11"x17")
3. ( wo(2)copies of the property survey.
Address: l B tN c,c, Iw7n CA t4ven�(�. 4. ( )Two(2)copies of the proposed site plan.
Phone# `I 11-q f Fo - {l le z 5. (/ One electronic/disc copy of the complete
application materials.
Applicant appearing before the Board: 6. ( F iling Fee.
7. ( )Any supporting documentation.
8. ( ),WA approval letter. (ifapplicable)
Address: 9. (4 Photographs.
Phone# 10.( )Samples of finishes/color chart. (a sample board or
Architect/Engineer: model may be presented the night of the meeting)
Phone#
By signature below, the owner/applicant acknowledges that he/she has read the complete Building Permit
Instructions&Procedures, and that their application is complete in all respects. The Board of Review reserves the
right to refuse to hear any application not meeting the requirements contained herein.
Sworn to before me this b Sworn to before me this
day of �,p�,` , 20 2-\ day of �pt�� , 2001
S ign-aTure of Property ter Signaftre4f Applicant
Danvel,k1=> wr an �G1n�ejl.t' 4 uszrrtn r,
Print Name Property Owner Print Name of Applicant
Nota ublic ota u lic
Ly&tte B. Coe
Notary Public. State of New York lII Lynette B. Cue
No. 0-006198669 Notary Public. State of New Yoi;;
Qualified in xpir chess County No. O:C061 JbbtSy
Commission] xpires Jan. 05, `1U3,� Qualified in We-tcliester County
Commission Expires Jan. 05, 21AC3/2,1/19
VILLAGE OF RYE BROOK
BUILDING DEPARTMENT
938 KING STREET, RYE BROOK, NY 10573
(T) 939-0668 (F) 939-5801
ARCHITECTURAL REVIEW BOARD
Wednesday, June 16, 2021
Due to public health and safety concerns from COVID-19, the Architectural Review Board
meeting on June 16, 2021 will be closed to members of the public. The public can still watch
the live meeting online through Zoom through the app or through the following
https://us02web.zoom.us/8/85411174403
If any interested members of the public would like to provide comments during the meeting,
comments can be emailed to stevefews@ryebrook.org or called in during the meeting at +1
(929) 205-6099, meeting ID: 854 1117 4403
NAME& LOCATION TYPE OF APPLICATION MOTION SECOND APPROVED REJECTED APPL.#
78 Woodland Ave - Replacement of Railing 5186
(Freeman) and Decking on Front O
Porch
5 Charles Lane Re-Do Existing Front Consent 5208
(Gasparini) Walkway In Blue Stone Agenda
1 Lincoln Ave (Parr) Replace Wood Retaining Consent 5209
Wall, w/Masonry Liberty Agenda
Stone, & Walkway
4 Candy Lane Replace Decking & Consent 5210
(Dluzhevskiy) Railing On Existing Deck Agenda
(PVC Paramount
Sandstone)
2 Charles Lane New 6' High Rear Yard Consent 5211
(Kaplan) Fence Agenda
16 Legendary Circle New Deck,New Patio, 5213
(Abramsohn) Retaining Wall, Expand
Driveway & Landscaping
18 Rocking Horse Amendment To Prior Consent 5214
Trail (Feist) Approval Fence Change to Agenda
Vinyl & Steps
23 Hawthorne Ave Outdoor Fire Place & 5215
(Quinson) Chimney
ML NM
MR SE
JM SF
AC MI
KC
39 Country Ridge Amendment To Prior 5216
Drive(Austrian) Approval (Pool House
Wrap Bottom In Stone
Veneer)
65 rock ridge Drive Relocate Patio Door,New 5217
(Ayala) Windows, To Facilitate
Inteiror Alterations
13 Knollwood Road Rear 1 Story Addition, 5218
(Luceno) Rear Deck, & Masonry
Patio
ML NM
MR SE
JM SF
AC MI
KC
VILLAGE OF RYE BROOK
BUILDING DEPARTMENT
938 KING STREET, RYE BROOK,NY 10573
(T) 939-0668 (F) 939-5801
ARCHITECTURAL REVIEW BOARD
Wednesday, May 19, 2021 PAGE 1
Due to public health and safety concerns from COVID-19, the Architectural Review Board
meeting on May 19, 2021 will be closed to members of the public. The public can still watch
the live meeting online through Zoom through the app or through the following
https://us02web.zoom.us/i/89843106184
If any interested members of the public would like to provide comments during the meeting,
comments can be emailed to stevefews@ryebrook.org or called in during the meeting at +1
(929) 205-6099, meeting ID: 898 4310 6184
NAME& LOCATION TYPE OF APPLICATION MOTION SECOND APPROVED REJECTED APPL.#
66 Tamarack Rd New 6ft White PVC Picket Consent 5185
(Sibley) Fencing Side Yards Agenda
78 Woodland Ave Legalize Replacement of 5186
(Freeman) Wood Deck Railing&
Boards w/Trex, &New
Paver Walkway.
112 Country Ridge New Rear Patio w/Fire Pit Consent 5187
Dr(Sandarciero) & Sitting Wall Agenda
14 Berkley Drive Replace& Enlarge Terrace Consent 5188
(Nachman) Patio,Add Built in BBQ Agenda
6 Birch Lane New 4Ft High Black Consent 5189
(Gitkind) Aluminum Fence In Rear Agenda
Yard
49 Rock Ridge Dr. New Rear Patio on Grade Consent 5190
(Firestone) (Blue Stone) Agenda
105 N. Ridge St New 4Ft High black Chain Consent 5191
(Sepkowski) Link Fence&4Ft High Agenda
Black Aluminum Fence.
34 Garibaldi Place 6Ft High White PVC Fence Consent 5192
(Crute) Side Yards Agenda
ML NM
MR SE
JM SF
AC MI
KC
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Laura Petersen
From: Laura Petersen
Sent: Thursday,July 8, 2021 1:16 PM
To: Danielle Freeman
Subject: RE: Building Permit Application - 78 Woodland Avenue
Attachments: BP -1 Form.pdf
Hi Ms. Freeman,
I have attached the BP-1 form which must be completed with a notarized signature. We will
need the original form.
We will also ne d the homeow ers insurance declaration page in which can be sent to me via
email. -- kecofv< 7
Please let me know if you have any other questions.
Thank you!
Laura
Laura Petersen
Office Assistant
Village of Rye Brook
938 King Street
Rye Brook, New York 10573
Phone(914)939-0668 1 Fax(914)939-5801 1 loetersenCcD,ryebrook.org
From: Danielle Freeman<dmf515@icloud.com>
Sent:Thursday,July 8, 2021 11:12 AM
To: Laura Petersen<LPetersen@ryebrook.org>
Subject: Re: Building Permit Application-78 Woodland Avenue
Good Morning Laura,
The work is being completed by the homeowner. Can you please provide the necessary paperwork that needs to be
completed and notarized?
Thank you,
Danielle Freeman
On Jun 18, 2021, at 11:51 AM, Laura Petersen<LPetersenPrvebrook.org>wrote:
Good morning,
i
The building permit application has been approved by the Building Inspector,
before I can issue the building permit the following items must be submitted to our
office,
1. General contractor's contact name & phone number.
2. Copy of general contractor's valid Westchester County Home Improvement
License.
3. General contractor's valid liability insurance (the Village Of Rye Brook must
be the certificate holder)
4. General contractor's valid workers compensation on a NY State Board form
(C105-2 or U26.3)
5. Building permit fee $100.00 (due once permit is issued and ready for pick-up)
6. Legalization fee $750.00 (due once permit is issued and ready for pick-up)
This information can be emailed to me.
Thank you
Laura
Laura Petersen
Office Assistant
Village of Rye Brook
938 King Street
Rye Brook, New York 10573
Phone(914)939-0668 1 Fax(914)939-5801 1 Ipetersenarvebrook.org
2
stab Fenn Fin and CaowM ConWeny
A Slodr Ooapany WNP Mon»Oplo a/n Sbomingbn,IIM0 e
Po Boar 88049
Atlanta G4 303669901 ^StateFarm
A13 H-28-7242-FCAC F HW DECLARATIONS
FREEMAN, DANIELLE aNI
98 BROOKSIDE PL
NEW ROCHELLE NY 10801-1806
AMOUNT DUE None
Payment is due by None
Policy Number. 32-CS-0292-8
Policy Period: 12 Months
Effective Dates:OCT 25 2020 to OCT 25 2021
The policy period begins and ends at 12:01 am standard
time at the residence premises.
HOMEOWNERS POLICY Your State Farm Agent
TOM BRODERICK
Location of Residence Premises 211 MAIN ST
78 WOODLAND AVE NEW ROCHELLE NY 10801.5712
RYE BROOK NY 10573-2946 a
Phone:(914)632-6000
Construction: Frame Roof Material: Composition Shingle
Year Built: 1915 Roof Inatallatton Year: 2018
Automatic Renewal
If the POLICY PERIOD is shown as 12 MONTHS,this policy will be renewed automatically subject to the premiums,rules,
and forms in effect for each succeeding policy period.If this policy is terminated,we will give you and the Mortgagee/Lion- a
holder written notice in compliance with the policy provisions or as required by law.
IMPORTANT MESSAGES
Zone:12 Subzone: 09
PREMIUM
Annual Premium $ 1,258.00
Your premium has already been adjusted by the following:
Home/Auto
Total Premium $ 12%00
Prepared NOV032020 Page 1 of 3
StateFarm
NAMED INSURED MORTGAGEE AND ADDITIONAL INTERESTS
FREEMAN,DANIELLE Mortgagee
LOANDEPOT.COM LLC Loan Number:
ISAOA/ATIMA 600202193
PO BOX 7114
TROY MI 48007-7114
Additional Insured
FREEMAN, THOMAS Loan Number
993 PINEBROOK BLVD N/A
NEW ROCHELLE NY 1 0804-1 809
SECTION I-PROPERTY COVERAGES AND LIMITS
Coverage Limit of Liability
A Dwelling $ 345,000
Other Structures $ 34,500
Building Ordinance/Law 10% $ 34,500
B Persoral Property $ 258,750
C Loss of Use $ 103,500
Fungus(including Mold) Limited Coverage $ 20,000
Additional Coverages
Credit Card,Bank Fund Transfer Card, Forgery, and Counterfeit Money $1,000 F
Debris Removal Additional 5%available/$1,000 tree debris
Fire Department Service Charge $500 per occurrence _
Fuel Oil Release $10,000
Locks and Remote Devices $1,000
Trees,Shrubs,and Landscaping 5%of Coverage A amount/$750 per item
SECTION II-LIABILITY COVERAGES AND LIMITS
Coverage Limit of Liability
L Personal Liability(Each Occurrence) $ 500,000
Damage to the Property of Others $ 1,000
M Medical Payments to Others(Each Person) $ 10,000
INFLATION
Inflation Coverage Index,343.5
DEDUCTIBLES
Section I Deductible Deductible Amount
Hurricane 5% $ 17,250
Other Losses $ 1,000
LOSS SETTLEMENT PROVISIONS
Al Replacement Cost-Similar Construction
Bt Limited Replacement Cost-Coverage B
32-CS-D292-8 AStateFarm
FORMS,OPTIONS,AND ENDORSEMENTS
HW-2132 Homeowners Policy
HO-2304 Amendatory Endorsement
HO-2684 Hurricane Deductible
HO-2687 Work Comp Select Residence Emp
HO-2403 Additional Insured
Option JF Jewelry and Furs$1,500 Each
Article/$2,500 Aggregate
Option ID Increase Dwlg Up to$ 69,000
Option Al Additional Insured
ADDITIONAL MESSAGES
State Fames works hard to offer you the best combination of price,service, and protection. The amount you pay for
homeowners insurance is determined by many factors such as the coverages you have,the type of construction,the
likelihood of future claims,and information from consumers reports.
Your premium was influenced by information from consumer reports:
Presence of a finance company installment account that has ever been 60 days or more late,Number of collection agency
filings,Number of accounts ever 30 days or more late, Number of consumer initiated inquiries for credit seeking
purposes in the last 24 months.
Please refer to the enclosed insert for additional details.
Other limits and exclusions may apply-refer to your policy
Your policy consists of these Declarations,the Homeowners Policy shown above,and any other forms and endorsemnnts
that apply,including those shown above as well as those issued Subsequent to the issuance of this policy.
This policy is issued by the State Farm Fire and Casualty Company.
Participating Policy
You are entitled to participate in a distribution of the earnings of the company as determined by our Board of Directors in
accordance with the Company's Articles of Incorporation,as amended.
In Witness Whereof,the State.Farm Fire and Casualty Company has caused this policy to be signed by its President and
Secretary at Bloomington,Illinois.
Secretary President
Prerured NOV 03 202C Peke 3 of 3
Affidavit of Exemption to Show Specific Proof of Workers' Compensation Insurance
Coverage for a 1, 2, 3 or 4 Family, Owner-occupied Residence
**This form cannot be used to waive the workers'compensation rights or obligations of any party.**
Under penalty of perjury, I certify that I am the owner of the 1, 2, 3 or 4 family, owner-occupied residence
(including condominiums) listed on the building permit that I am applying for, and I am not required to show
specific proof of workers' compensation insurance coverage for such residence because (please check the
appropriate box):
❑ I am performing all the work for which the building permit was issued.
❑ I am not hiring,paying or compensating in any way,the individual(s)that is(are)performing all the work
for which the building permit was issued or helping me perform such work.
I have a homeowners insurance policy that is currently in effect and covers the property listed on the
attached building permit AND am hiring or paying individuals a total of less than 40 hours per week
(aggregate hours for all paid individuals on the jobsite) for which the building permit was issued.
I also agree to either:
♦ acquire appropriate workers' compensation coverage and provide appropriate proof of that coverage on
forms approved by the Chair of the NYS Workers' Compensation Board to the government entity issuing
the building permit if I need to hire or pay individuals a total of 40 hours or more per week(aggregate hours
for all paid individuals on the jobsite)for work indicated on the building permit,or if appropriate,file a CE-
200 exemption form; OR
♦ have the general contractor, performing the work on the 1, 2, 3 or 4 family, owner-occupied residence
(including condominiums)listed on the building permit that I am applying for,provide appropriate proof of
workers'compensation coverage or proof of exemption from that coverage on forms approved by the Chair
of the NYS Workers' Compensation Board to the government entity issuing the building permit if the
project takes a total of 40 hours or more per week(aggregate hours for all paid individuals on the jobsite)for
work indicated on the building permit.
7—/ O - -Lod ,
ignature of H meowner) (Date Signed)
Dante 1t-e tV_e_rn0.n Home Telephone Number 1,1 gl(rj-t-{ 1p2
(Homeowner's Name Printed)
• Sworn to before me this 4- day of
Property Address that requires the building permit:
-18 NOodIG1nCJ AVenu
G� (Co ty e r blic) •
US�� e, State
Gof
Notary P lie, State of New York
No. 0'CO6198869 j
Qualified in Westchester County
Commission Expires Jan. 05,20
I
Once notarized,this BP-1 form serves as an exemption for both workers'compensation and disability benefits insurance coverage.
BP-1 (12/08) NY-WCB
YkI— V 1.TC ONVUK / IVT O1 N7C
SHEET 135.075
BLOCK 1
LOT 69
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2-14281 FOL-29
AS-31JILTIFINAL SURVEY
�7
PERMIT; J1 �� / REQUIRED PRIOR TO
SBL# l 3S- 7S -' L , FINAL INSPECTION
DATE APPR I D
BUILDING INSPE TOR RFAP:RE-:9
O ge of Rye Brook,NY
2021
VILLAGE OF RYE BROOK
BUILDING DEPARTMENT