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Home My WebLink AboutBP21-200PERMIT #'6i�l ' Q00 DATE: �� EXP SECTION �3 , 75' OwnBLOCK � LOT TYPE OF WORK :21 t7 /" / P a,�7i JOB LOCATION *7,5'VO/7 e TRACTOR l-GZ ri-� !/ LT/J Jco h EST. V 0# TCO # FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING RGH PLUMBING GAS LD .31C 3- P IL ff i bATF I / ;Q = FEE pgTE INSPECTION RECORD DATE INSP SPRINKLER ELECTRIC LOW -VOLT O ALARM 0 AS BUILT (� FINAL -V30 � �� 9/�l�b �/o•�S ZLG eliviNdirliVoillifAl lRb ZBA OTHER Expired Letter Sent 10/6/2022 VILLAGE OF RYE BROOK WESTCHESTER COUNTY, NEW YORK No: 22-180 Certif i cate of Occupancy 'This is to certify that %Onx of, R)�c '�Ycx� �, /V y , having duly filed an application on 3: 10ir, 20(� requesting a Certificate of Occupancy for the premises known as, 7-5 3 AV d)�) 6e'-C J-e , Rye Brook,NY, located in a Zoning District and shown on the most current Tax Map as Section: C Block: �Lot: 3. and having fully complied with the requirements of the Building Code and the Zoning Ordinance under Building Permit No. , issued 3 20 07 I, 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, UseS E.Jone, r /IV Construction: for the following purposes: /" e�'/� /'k 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 heigh shall made,nor shall the building be moved from one location to another until a permit to accomplish such change has bee o tai ed ing Spector. Building Inspector,Village of Rye Brook: ate: NOV 2 3 2022 BUILDINd&kRTMENT For office use onl,*: i PERMIT# aU VIL_LAG1J OF RYE BROOK ISSUED: — 1 W D R� r KING STREET,RYE BROOK, NEW YORK 10573 DATE: �2r (914)939-0668:-);, FEE: ��NN 8 2022 , AM OR RTIFICATE OF OCCUPANCY, CERTIFICATE OF COMPLIANCE, VILLAGE OF RYE BROOK AND CERTIFICATION OF FINAL COSTS BUIL DING-DEPART MENT ITTED ONLY UPON COMPLETION OF ALL WORK, AND PRIOR TO THE FINAL INSPECTION Address: j {-� hLrOv) t D o lk /V O S Occupancy 7 se RCsj j1e j Parcel ID#:_ 3 7J� C:) / // Zone: ,7— i Owner: (re-9.1 rrsCe— %raquP Address: 1Sit to,, C /ook /V V ldS P.E./R.A. or Contractor: f"�,rr�� `�{/�. Address: j8fao k.,-e L ��, SfoIM7e,Ot Person in responsible charge:�� ,� J:Q4,fe. Address: Application is hereby made and submitted to the Building Inspector of the Village of Rye Brook for the issuance of a Certificate of Occupancy/Certificate of Compliance for the structure/construction/alteration herein mentioned in accordance with law: STATE OF NEW YORK,COUNTY OF WESTCHESTER as: being duly sworn,deposes and says that he/she resides at 1 bf oo k-,%Ie- (p l- (Print Name of Applicant) (No.and Street) in 5 L>P9 rd in the County of J/dI in the State of`'•i . that (Cm Town/Villaec) 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: for the construction or alteration of: 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 '1 f Sworn to before me this day of 1-�j 11fL� , 20z2— day of J y � 20 2Z Signature of Pulcm Owne Nignature ot Applicant JET Fa Print Name roperty Own r 13M CAPECI Print Name of Applir t NOTARYTATE OF NEW VM Registration .OICA4859" _ tebester Coun Notary Public res May I9,2��j/_ of is �C DREW ALEXANDER Notary Public of New York I.D.01AL641646 COMMISSION EXPIRES 03/01/2025 QyE BRO O�` tim BUILDING DEPARTMENT gUILDING INSPECTOR SSISTANT 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 O o DATE: PERMIT# �� 1� ISSUED:I` I SECT: > BLOCK: LOT: LOCATION: �' 'plc OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... i� ACCEPTED ❑ REJECTED/REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ,.❑ ROUGH PLUMBING ❑ ROUGH FRAMING [I INSULATION ❑ NATURAL GAS ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑� ]ROSS CONNECTION FINAL OTHER t + s' [� si ai N00 00W N N Ln a W \ \ 0 00 00 _ ►—� , � Q � � x s O O ^^ u \ C A a O cri s: z a M .. (� A 00^ W z �D A U ►.. + ' Z O \ [� z � 0.4 CN 00 ~ w z MM � u U 0 C7 a o n � Zs a zF Q+ + Ln og v 4 w z a °` x .. a w a a � H 0 z w = � i ' tic,(19Vutt 4;444A4vototCmt%94144t;t4 16t�64164to (mot j�� r!� �- j; �••,.,� _-_ I _lE dRv,� BUILDING DEPARTMENT AUG ' 5 2022 VILLAGE OF RYE BROOK — 938 KING STREET RYE BR+ox,NY 10573 VILLAGE OF RYE_ BROOK (914)939-0668 L BUILDING DE PA.RTMENT wwwTg ELECTRICAL PERMIT APPLICATION Westchester County Master Electricians License Required I FOR OFFICE USE ONLY BP#: "�00 EP#: Approval Date: AUG — 8 1021 Permit Fee: $ Approval Signature: Other: Application dated, <' O- is hereby ma to the Building Inspector of the Village of Rye Brook NY, for the issuance of a Permit to install and/oi re ove electrical equipment,wiring, fixtures, or to perform other high or low voltage electrical work as per the detailed statement described below. By signing this document, the applicant & property owner agree that all electrical work performed will be in conformance with all applicable Federal,State,County and Local Codes 1.Address: 7Y 3 /9 V t7?J SBL: I3 J, 7 r- 2- V/ .j Zone: L 2.Property Owner: S R 1}(,.;C-W— Address: 73-X /1 V D k-, C Phone#: Cell#: Of / 8 3-7 --d 7 3 6 email: 3.Master Electrician: Address: )xi=GJ/C 4fZC Lic.#: / Phone#: 9/'f ,�"j��' Cell#: email: 01-2 t or) Company Name: Address: 4.Proposed Electrical Work/Fixture Count: KJ Pee wa Z/1 7—/ 5.3'Party Electrical Inspection Agency: STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: ,being duly swom,deposes and states that he/she is the applicant above named,and does further (print name of individual signing as the applicant) state that(s)he is the legal owner of the property to which this application pertains,or that(s)he is the for the legal owner and is duly authorized to make and file this application. (indicate architect,contractor,agent,attorney,etc.) The undersigned further states that all statements contained herein are true to the best of his/her knowledge and belief,and that any work performed,or use conducted at the above captioned property will be in conformance with the details as set forth and contained in this application and in any accompanying approved plans and specifications,as well as in accordance with the New York State Uniform Fire Prevention&Building Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances,and regulations. Sworn to before me this Sworn to before me this S day of ,20 day of ,20_aD _ Signature of Property Owner Signature of Applicant Print Name of Property Owner ame of Applicant Notary Public Notary Public SHARI MELILLO Notary Public,State of New York No.01ME6160063 Qualified In Westchester County r23ao22 Commission Expires January 29,20,� STATEWIDE • Service With ltay.griq 0:0 Swias JOBAPPLICATION Office Use Elect.Permit# !r� 1�_ / '] Date Bldg Permit# Utility ID# � P /*� --;� / - -) ov Final Certificate# City/Village A L LI) �_ � i Zjp � Township County Address 7,6— 43 /1 V,J C Cross Street Section �r Block TLot Owner Name/Address(if different than above) Contact Number J ❑Basement ❑ 1st Fl. ❑2nd Fl. ❑3rd Fl. ❑More Than 3 Fl. ❑Garage ❑Attic ❑Outside ❑Residential [:]Commercial , - Receptacles Special Recept GFCI AFCI Switches Dimmers Smoke Alarms Carbon Monox Hood Trash Compact Amt Amps Range(s) Cooktop(s) Oven(s) Dishwashers Refrigerator Disposal Microwave Warm Draw Incandescent Fluorescent SERVICE Amperage Voltage 1 P 3P #Meters #Disconnect ❑Underground ❑New ❑Reconnect ❑Overhead ❑Change ❑Visual Re-Inspection ❑ Safety Re-Inspection ❑ Re-Inspection Additional Information C ► ►C l-1 r-J r I+V o J P1+ Ir / c� D CC� EE-7OMC AUG - 5 2022 � VILLAGE OF RYE BROOK BUILDING DEPARTMENT This application is valid for one(1)year from the date received by sWls.This application is interded to cover the above listed items to be inspected,If at any time of inspection additional items have been installed you art authorized to make the inspection and adjust the fee for the additional Items inspected.The applicant declares that there is no open applications for the above address with any other Inspection company.The applicant,owner or authorized agent agrees to all the above terms and conditions as set forth for the application. Inspector Date Finalized Inspector# Company Name ( = Date Signature J l Address City/State Zip Code License# 1 1 Phone# State Wide Inspection Services 1080 Main Street Fishkill, NY 12524 a 845 202-7224 Phone 914-2194-219-1062 Fax STATE WIDE INSPECTION SERVICES Email: office@swisny.com Website: www.swisny.com Service With Integrity BY THIS CERTIFICATE OF COMPLIANCE STATE WIDE INSPECTION SERVICES CERTIFIES THAT: Upon the application of: Upon Premises Owned by: Faigle Elec Contractors Inc. George Sprague 64 Newkirk Road 75 B Avon Circle Yonkers, NY 10710 Rye Brook, NY 10573 Located at: 75 B Avon Circle, Rye Brook, NY 10573 Section: Block: Lot: Electrical Permit Number: EP22-177 Certificate Number: 2022-4577 Building Permit Number: BP#21-200 A visual inspection of the electrical system was conducted at the Residential occupancy described below.The electrical system consisting of electrical devices and wiring is located in/on the premises at: 75 B Avon Circle, Rye Brook, NY 10573 The First Floor Kitchen was inspected in accordance with the NYS and NFPA 70-2017 and the detail of the installation, as set forth below,was found to be in compliance on the 11th day of August 2022. Name Quantity Rating Circuit Type GFCI Receptacle 01 Light Above Sink 01 GFCI Receptacles Island 02 Dishwasher 01 Refrigerator 01 Under Cabinet Lights 04 State Wide Inspection Services did not perform a Rough inspection (Rough Performed by WREIS).A Visual inspection and Final inspection were conducted only. /J I Ir Officer: Frank J. Farina This certificate may not be altered in any way and is validated only by the presence of a seal at the location indicated.This certificate is valid for work performed on the date of inspection only. i cli rl I i � Q O M = r ~ gp OC C96 G. .. w ICI O ` M� O z o a o z o w a u , � � _ O Q F CO � w A L �. V C� O w � O w 1 z° W z `� 8 Z � n 04% m Ono 000 W Q ! �.. CN O Q a a e c V � z � Q z a �g > c m M� ooen �g w W6 E cx o 0 3 w F a W �- w 00 z g ✓� � w F" w .• C � e C Q to U ral z 4 6 , OG p CC EHE ��Dw.� BUILDING EiPARTMENT OCT 13 2021 VILLAGE OF RYE B� OK VILLAGE OF RYE BROOK 938 KING STREET RYE. 19 t .B ,NY 10573 BUILDING DEPARTMENT or ELECTRICAL PERMIT APPLICATION Westchester County Master Electricians License Required^^,, 1,, FOR OFFICE USE ONLY P ��' O 0 EP#: r�l o)401 Approval Date: OC Permit Fee: $ 15� '—Ay 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 conformance with all applicable Federal,State,County and Local Codes. 1.Address: 7-f L /v SBL: 1.31 Zone: 2.Property Owner: U Address: 7 5- �f.8 ✓Oi!(f/i-G JQ Axle Z.- VoOleJv 7 Phone#: Cell#: 7— 734 email: 3.Master Electrician: LC_ Address: tO AQWk'jrie OQ Oike/.S NYIOWt Lic.#: /8 al Phone#:f/#—79.3-569 ell#: email: Company Name: Address: n eZ 4.Proposed Electrical Work/Fixture Count: STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: being duly swom,deposes and states that he/she is the applicant above named,and does fitrther (print name of individual signing as the applicant) state that(s)he is the legal owner of the property to which this application pertains,or that(s)he is the for the legal owner and is duly authorized to make and file this application. (indicate architect,contractor,agent,attorney,etc.) The undersigned further states that all statements contained herein are true to the best of his/her knowledge and belief,and that any work performed,or use conducted at the above captioned property will be in conformance with the details as set forth and contained in this application and in any accompanying approved plans and specifications,as well as in accordance with the New York State Uniform Fire Prevention&Building Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances and regulations. Swom to before me this Sworn to before me this day of ,20 day of ,20 Signature of Property Owner Signature of Applicant ,,4"d %`/-�-i aZ Print Name of Property Owner Print Name of Applicant Notary Public Notary Public 8/12/2021 Westchester Rockland Electrical Inspection Services, Inc. '- Phone: 914-347-3595 DO NOT VRITE HERE-FOR OFFICE USE ONLY 43 North Lawn Avenue Fax, 914- 7-3596 Elmsford, NY 10523 BUILD ;P;EjR7NO. TEMP# A�:; 0 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 OCCUPANT'S NAME,— U BUILDING OCCUPANCY OWNER'S NAME AND ADDRESS HOME V d/V ��l(C or- oO HOME TELEPHONEI 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 REACH- ATTS EACH INSPECTION OUTSIDE r BASEMENT If FL. Ll O T 13 2021 I 2-FL. 3-FL. BUILD! JG DEPARTMENT T REMARKS:LIST OTHER ELECTRICAL DEVICES NOT SET FORTH ABOVE: 1 F N 0 U 7 1t� ti Q -el C H E•�-� 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 APPUCANT DECLARES THAT THERE IS NO OPEN APPLICATIONS FOR THE ABOVE WITH ANY OTHER INSPECTION COMPANY.WREIS,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❑ ADDITIONAL❑ EXPOSED❑ CONCEALED❑ MUST ENTER APPLICANTS IDENTIFICATION NUMBER SERVICE ENTERS BUILDING OVERHEAD❑ UNDERGROUND❑ f 0 A 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 SIGNATURE OF APPLIC STREET ADDRESS TELEPHONE NO. �y J wx�2/C CRY oILPOET OFFM ZIP CODE LICENSE NO.WHEN APPLICABLE / i' i' i' N N N W o a � Ur w v o, � "� W �} ►--� C `� � � � QQpp x s I--I N O A 6J `n z � F 1 � F 010 � Ci f C x a x ° 1z r r W � LL; z , � (A w 00 z Vz � (� O Coe g pa z i� V U v z � o w w w .' Ln . z F x V o w • c7 A O v C. � �,,♦ Q O � Ri D BUILDING DEPARTMENT OCT 13 2022 VILLAGE OF RYE BROOK 938 KING STREET RYE BROOK,NY 10573 VILLAGE OF RYE BROOK (914)939-0668 BUILDING DEPARTMENT wwwA + ook.org ELECTRICAL PERMIT APPLICATION Westchester County Master Electricians License Required 1 FOR OFFICE USE ONLY BP#: QI-'�;>00 EP#: OCT 1 3102 Approval Date: Permit Fee: $ Approval Signature: Other: 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. By signing this document, the applicant & property owner agree that all electrical work performed will be in conformance withall applicable Federal,State,County and Local Codes. ��1.Address: � Amtn ( ,/e r,2 . SBL: IJ S-7S ' Zone: 2.Property Owner':/ p&e '5t 5P i�ue �/ Address: vp C T rG C Phone#: -I- b 3 7- 3S ,�," � Cell#: 1 -( $3 7- 7 2 3 6 p�emmail: r ( .t 3.Master Electrician: R! �.�u tVv �� Address: p ` �" ��fZ y� � Cda ' Lic.#: Ii.1—�_Phone#: Cell#: -G CI&Y,5'email: Company Name: Address: 4.Proposed Electrical Work/Fixture Count: re to c f-ed P C4-I r t 0/2 4 �-r(f I �5 5.31 Party Electrical Inspection Agency: STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: ,being duly swom,deposes and states that he/she is the applicant above named,and does further (print name of individual signing as the applicant) state that(s)he is the legal owner of the property to which this application pertains,or that(s)he is the for the legal owner and is duly authorized to make and file this application. (indicate architect,contractor,agent,attorney,etc.) The undersigned further states that all statements contained herein are true to the best of his/her knowledge and belief,and that any work performed,or use conducted at the above captioned property will be in conformance with the details as set forth and contained in this application and in any accompanying approved plans and specifications,as well as in accordance with the New York State Uniform Fire Prevention&Building Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances,and regulations. Sworn to before me this Sworn to before me this r D day of ,20 day of / ,20 >_ Signature of Property Owner S' a�P ant "� V✓vL Print Name of Property Owner Print N to of Applicant Notary Public Notary Public &23/2022 STATE WIDE INSPECTION SERVICES, INC. CPA--) Service VVith lnlegrij�y 0•0 • • SWIS JOB APPLICATION •. • Office Use Elect. Permit# Date ` Bldg Permit# ^' Scl Ft J I Plumbing Permit# Final Certificate# City/Village Zip Building Dept. ` County J Address _i Cross Street Section S Block Lot Owner Name/Address(If different than above) Contact Number /L-/- 7 i -7 ❑Basement ❑ 1st Fl. ❑2nd Fl. ❑3rd Fl. ❑More Than 3 Fl. ❑Garage ❑Attic ❑Outside ❑Residential ❑Commercial Receptacles Special Recept GFCI AFCI Switches Dimmers Smoke Alarms C/0 Detector Hood Trash Compact Amt Amps Range(s) Cooktop(s) Oven(s) Dishwashers Refrigerator Disposal Microwave Luminaires Generator Transfer Switch i SERVICE Amperage #Panels 1P 3P #Meters # Disconnect ❑Underground ❑ New ❑ Reconnect ❑ Repair ❑Overhead pgrade ❑ Disconnect Utility ID# ❑Con Ed ❑ NYSEG ❑Central Hudson ❑ Orange/Rockland PHOTOVOLTAIC SYSTEM PV Modules Inverters AC Disconnect Junction Box Combiner Box Load Center PV Monitor Energy Storage System DC Disconnect ❑Legalization ❑ Safety Inspection ❑Consultation t � Gig Q - C [ DI vE t F CT 13 2022 VILLAGE OF RYE BROOK BUILDING DEPARTMENT This application is valid for one(1)year from the date received by SWIS.This application is intended to cover the above listed items robe inspected,if at any time of inspection additional items have been installed,you are authorized to make the inspection and adjust the fee for the additional items inspected.The applicant declares that there is no open applications for the above address with any other inspection company.The applicant, owner or authorized agent agrees to all the above terms and conditions as set forth for the application. Email Address !}."Pr 14114 i U( r'irJ f �, it l�� F f� - Name f i License# _ Date f('/j 7� ? Signatures% !L/�'�7 Y� _ ` Address ( ' '�'i,' .- r City/State it-"✓G 1 1 Zi VCode 6 C,(CO Company 6- G ,�6'Ltd L � V�i f' �:-'(" /� i Phone# D IEC IEOW IF State Wide Inspection Services CA(�> 3D 1080 Main Street NOV — 9 2022 Fishkill, NY 12524 TO � 845 202-7224 Phone VILLAGE OF RYE BROOK 914-219-1062 Fax STATE WIDE INSPECTION SERVICES BUILDING DEPARTMENT Email: office@swisny.com Website: www.swisny.com Service With Integrity BY THIS CERTIFICATE OF COMPLIANCE STATE WIDE INSPECTION SERVICES CERTIFIES THAT: Upon the application of: Upon Premises Owned by: Grandview Electric George Sprague Roy Duckworth IV 75 B Avon Circle 87 Greenleaf Drive Rye Brook, 10573 Stamford,CT 06902 Located at:75 B Avon Circle, Rye Brook, 10573 Section: Block: Lot: Electrical Permit Number: EP 22-244 135.75 43.1 Certificate Number: 2022-7238 Building Permit Number: BP 21-200 A visual inspection of the electrical system was conducted at the Residential occupancy described below.The electrical system consisting of electrical devices and wiring is located in/on the premises at: 75 B Avon Circle, Rye Brook, 10573 The First Floor Kitchen was inspected in accordance with the NYS and NFPA 70-2017 and the detail of the installation, as set forth below,was found to be in compliance on the 31st day of October 2022. Name Quantity Rating Circuit Type Recessed Luminaires 12 Switches 02 Panel 01 100AMP Officer: Frank J. Farina This certificate may not be altered in any way and is validated only by the presence of a seal at the location indicated.This certificate is valid for work performed on the date of inspection only. �4 x N I N pi O � � N N N r Aw 1-0 DIU cli ■ j W V ■ .. N o g �/ 1n W v Q U = .� Y r 47 (: h+�l ry U a r r ■ O E— co 00 W M NO W 10 C Z t . r p, x v U �D '7 Q 00 ^� Grp C tI r, r, ba' } C or " = , cc tj ; I� FBI �I U O a V�y C4 ►^ f� v Z un N Lz96 t, rA U O O r � i .. a Z 96 i R [� C� DOMD BUIL EJB , ENT AUG 18 2021 V[L E;ET F ROK 938 KIN , RY NY 10573VILLAGE OF RYE BROOK BUILDING DEPARTMENT — --__ o ELECTRICAL PERMIT APPLICATION Westchester County Master Electricians License Required / FOR OFFICE USE ONLY III,#: L VD EP#: 0I—�O 47 AUG 1 8 2 ,Q Approval Date: Permit Fee: $ Approval Signature: V 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 conformance n li with all applicable Federal,State,County and Local Codes. 1.Address:—7_�R //(/M C..IO-blQ SBL: �`.'�' 7S-7 43 e'Zone:444, 2.Property Owner: 9fftVfeAddress: 7_S� UQ(/( CU r Phone#: R Cell#: 9/414,3 7— to emaail:,^ 3.Master Electrician: 'xO0 t?c jkW k Address: 87 Cweehy ,. / /ry Lic.#: 17 a Phone QG�eI #: email:q�•` (;1,er-1et� ��it C'Ci Company Name: !j r4Q U j CV ?I t`& Address: NJ �ll 4.Proposed Electrical Work/Fixture Count: �d urn .9uAVl 04/1 Ct ' STATE OF NEW YORK,CO OF WESTCHESTI?R ) as: Bing duly swom,deposes and states that he/she is the applicant a ove named,and does rther (print nan of individual signing as the appl' ant) f a state that(s)he is the legal owner of th property to which this application pertains,or that(s)he is the for the legal owner and is duly authorized to make and file this application. (indicate architect,contractor,agent,attorney,etc.) The undersigned further states that all statements contained herein are true to the best of his/her knowledge and belief,and that any work performed,or use conducted at the above captioned property will be in conformance with the details as set forth and contained in this application and in any accompanying approved plans and specifications,as well as in accordance with the New York State Uniform Fire Prevention&Building Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances and regulations. Sworn to before me this Sworn to Wore me this day of ,20 Samantha Duckworth day of _ Notary Public-Connecticut My Commission Expires Signature of Property Owner N o v e m b s r 3 0,2 0 2 37 Si ture of Appl icant Print Name of Property Owner Prin o plic Notary Public otary P is 8/12/2021 Westchester Rockland Electrical Inspection Services, Inc. M y Phone: 914 34 593 • DO NOT WRITE HERE-FOR OFFICE USE ONLY 43 North Lawn Avenue Fax: 914-347-3596 Elmsford, NY 10523 BUILDING PERMIT NO. TEMP# DATE F �'G'l - ZGU CITY OR VILLAGE ZIP CODE TOWNSHIP / COUNTY STREET AND NO.OR ROAD 61POLE NUMBER BETWEEN WHAT TWO CROSS STREETS IS PREMISES LOCATED? SECTION BLOCK LOT / OCCUPANT'S NAME Sc(j 1 p- ILDING OCCUPANCY OWNER'S NAME AND ADDRESS l J !✓1 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 NO. H.P.EACH NO. WATTS EACH INSPECTION OUTSIDE BASEMENT 1"FL. 2—FL. VILLAGE OF RYE BROOK 3'FL. TME REMARKS:LIST OTHER ELECTRICAL DEVICES NOT SET FORTH ABOVE: r)CG (/It' e- " Ltf " 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.WREIS,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,I ADDITIONAL❑ EXPOSED❑ CONCEALED O MUST ENTER APPLICANTS IDENTIFICATION NUMBER SERVICE ENTERS BUILDING OVERHEAD❑ UNDERGROUND❑ LLI I I I I AVOID DELAYS BY GIVING FULL AND ACCURATE INFORMATION.ALL SPACE MUST BE FILLED IN OR APPLICATION MAY BE RETURNED. NAMME'OF COMPANY / DATE OF APPLICATIONSIGNATURE OF APPLICANT Ptv r 17'CAriC bi �l X $RaEETADDRE88 TELEPHONE NO. CRY OR POST ZIP CODE, LICENSE NO.WHEN APPLICABLE v I n 10 a Clq 06 C. lob o b O � Q W co moo aN Q f O z ■i pC, � � Q w � a � u � O � 00en MCI CISONO o M O � < 0 U a � �p _ < R C� C�' EW BUILDING DEPARTMENT OCT - 7 2021 VILLAGE OF RYE BROOK VILLAGE OF RYE BROOK 938 KING STREET RYE BRooK,NY 10573 BUILDING DEPARTMENT (914)939-0668 www.rycbrook.org PLUMBING PE/RMI'T APPLICATION FOR OFFICE USE ONLY BP#: / PP#: CD — a Approval Date: OCT ` 8 Ml Permit Fee: $ Approval Signature: Other: /1 e Disapproved: Itr (fees are non-refundable) Application dated, Ct I 1 b'd) 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,State,County and Local Codes. !� I.Address: 9 5 6 Qvo N Ci 2 d C_ SBL: � � 7�'�"73 r/ Zone: ,e - 2.Proposed Work: Li�c11 tn) v0IV e-S d Ra(N Re_la tiIffyv Shn�Pa [:us�ail nti r YES 1'iuc� 3.Property Owner: 6to 9.rc S p�6 uL, Address: 3,19 Avon; C,e-gA e R e gacr)14 Phone#: (6110 $3-j- 933(. Cell#: email:T(uc 'l�( � vc l�►o��.c�/i, 4.Master Plumber: k.t (C S 21(-VA Address: 3q)( Colu rti 17.,s A\e . l Va ll k,16 luY Lic.#: �(,S Phone#: (I N)�q—0l13t'Cell#: email: Se 2y,Lt P "Met"" c aON Company Name:� 2.M . nfumhiNfr � h e,, 'Ny nC.Address: 3ei- ('171yrnbjs ke VIA��c��, INDICATE FIXTURES&LINES TO BE INSTALLED AS PER THE FOLLOWING SCHEDULE: Location Water Urinals Drinking Sinks Showers Bath Laundry Domestic Fire Sanitary Natural/ Other* Total Closets Fountains Tubs Tubs Service Service Sewer LP Gas Basement 1st Floor 2nd Floor 3"d Floor 41 Floor 5"Floor Exterior 5.*List Other Equipmenv?rovide Details: (Notarized Signatures Required Next 2 Pages) -1- 8/12no2t STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: G /`pi,- n r 22;0 i 1P being duly sworn,deposes and states that he/she is the applicant above named, (print narnyf individpill signing as a applicant) and farther states that(s)he is the legal owner of the property to which this application pertains,or that(s)he is the koh'QX 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 efore me this Z day of ,20 91\\ day of ,20VtI Signature&0roperty giOner Signa a of Applicant /" O Print Nar6Vof Propeof Owner jY Print a of Vh6ant L Public A D H.MARS otary Public Notary Public,State of New York NORINE MEYER No.O1FR6363711 Notary Public,State oI New York Qualified In Westchester County Llc•No.01 ME813o633 OuallRed in Westohester Cou Commission Expires August 28,20 Commission Expires July 25,20 This application must be properly completed in its entirety and must include the notarize —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- 8/12/2021 �' BUILDING DEPARTMENT (� D � L� VILLAGE OF RYE BROOK OCT - 2021 938 KING STREET RYE BRoov,NY 10573 ILI (914)9 68 39-5801 VILLAGE OF RYE BROOK BUILDING DEPARTMENT AFFIDAVIT OF COMPLIANCE VILLAGE CODE§216 - 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 YORK, COUNTY OF WESTCHESTER ) as: cje�=Q_ f-)PLaa ' , residing at, _7 j'l� (21e 1?yL e)rtti6K (Print n e) J (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; 75-6- N rX—sycN2,1�y�ru-L , 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 qfProperty Ow s)) S (Print Namejf Prope Owne )) Sworn to before me this COVDay of Q� , 202) NORIN■MRYeR A Notary Public,StWe of New York / Lic.No.01 ME6130633 OualMed in Westchester County, (Notary Public) Commission Expires July 25,20 (6) 3/21/19 AFFIDAVIT IN SUPPORT OF FEE WAIVER RELATED TO HURRICANE IDA STATE OF 1 COUNTY OF �C�12S r 2 eT nsert name), being duly sworn, deposes and says 1. I am the applicant for a Building Permit/Certi to of Occupancy/Demolition Permit Electrical Permit/ �nbi j Permit/Fence & Wall Permit Mechanical Permit/Pod Permit (circle all that apply) 02. lam the legal owner of property located at -75"B ALpy) &ck Rye Brook,New York (insert street address) OR I am the (Architect/Contractor/Engineer/Attorney) (circle one) for the legal owner of property/ J located at Z 47 , � /�L /` L �� , Rye Brook,New York and I am duly authorized by property owner to make and file the accompanying application. 3. The following is a description of(1) the work to be performed under the permit for which I am applying; and (2) how the work arose as a direct result of Hurricane Ida: �mWt K,i lc. pin 0011L)& lomA lwue. dvo,+n no—tor- t �cSyl .S�a�P,t� 11'1� 11 t X')Ce-- 4. The work described herein arose as a direct result of Hurricane Ida and does not include Work which was not caused by Hurricane Ida. Sworn to before me this of Cr- PQr , 202i AQw 1 Notary Publi NCRINB Mooft Notary Pubiic,Stat of lew York Lic.No.01ME ""— ouaiiw in Westchester Coun ,-, Commission Expires Juiy 25,20DD _ OCT - 7 2021 VILLAGE OF RYE BROOK BUILDING DEPARTMENT �yE LOD 1�w4 V„y . 19 404 annivooatV VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914) 939-0668 Christopher J.Bradbury w%vw.ryeb rook.org TRUSTEES BUILDING& FIRE INSPECTOR Susan R.Epstein Michael J. Izzo Stephanie J. Fischer David M.Heiser Salvatore W.Morlino October 6,2022 Dear Rye Brook Building Permittee, It has come to the attention of the Building Department that your Building Permit has not been closed out in accordance with Village Code and is now expired.All Building Permits have a twelve(12)month lifespan starting from the date of issuance,and the permit expiration date is noted on the front of the permit. Please note that there is a non-waivable Expired Permit Fee of$500.00 now due in connection with your expired permit. Once payment is received,your permit will be reinstated for a period of six(6) months. Please be advised that it is a violation of Village Code to fail to close out a permit,and that a court summons could be issued,and fines may be imposed on the permit holder and/or property owner for failure to apply for and obtain a Certificate of Occupancy(C/O) or Certificate of Compliance(C/C),in accordance with Village Code section 250-10A. Please note that Temporary C/Os&C/Cs are available in accordance with Village Code section 250-10B should you require more time to perform whatever work remains in order to complete your project. Thank you for your attention in this matter,and please feel free to contact this office should you require any further information. Michael J. Izzo Building&Fire Inspector mizzoO,ryebrook.org /to cc: Steven E. Fews,Assistant Building Inspector Tara A. Orlando,Planning&Zoning Secretary Laura Petersen,Office Assistant O L WI O i � Cf) 5209 M O O v °' 3 &� z En C 0 0 0 u � c7 � x Y c � Z CO CC m °r� r�"�'�� b ►L v 3�11\r W a� V � Q J of J c ]C M O` Building Permit Check List&Zoning Analysis Address: 7L 3 A%j(D N Ct/L C SBL Zone:_Use: Lk t O Const.Type: 3 Other. Submittal Date: 'I Z f Revisions Submittal Dates: Applicant: S ►�R,A.C y F� Nature of Work Reviews:ZBA AUb 2 2021 PB: BOT: Other. OK ( ( ) FEES:Filing. 7 S, � BP: 920 - — C/O: Legalization: APP: Dated Notarized ✓SBL: —Truss I.D. Cross Connection: H.O.A.: ( ) ( ) Scenic Roads: Steep Slopes: Wetlands: Storm Water Review: Street Opening. ( ) ( ) ENVIRO:Long. Shorn Fees: N/A: ( ) ( ) SITE PLAN:Topo: Site Protection S/W Mgmt.: Tree Plan: Other. ( ) ( ) SURVEY:Dated Current: Archival: Sealed: Unacceptable: ( ) ( ) PLANS:Date Stamped Sealed Copies: Electronic Other. ( ) (,), License: -" Workers Comp: Liability: -**/ 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. ( )ARB mtg.date: approval: notes: ( )ZBA mtg.date: approval: notes: ( )PB mtg.date: approval• notes: REQUIRED EXLSTING PROPOSED NOTES AUG _ c G� 2021 �: Date: Circle: Fr n e Front Front Sides: Rear. Main Cov Accs.Cov Ft.HS : S .H Sb: Tot,Imp: Ft.Imp: PP Height/Stories: notes: S.. .Srri �rn WWF 1F .� A� A h .. /AI ^ �! ygyAapyt F. - •� A A F. � A AA��- _.� 11/11 11111 11111 �• Il///j � j/(1.1j � j/•1♦1► � � 1/.1.1 � F ::.._ �- 11111111111.. „111111111111•' t 3F10111'1►1111'#,y $ae;,11111/111i11�t gesx:.4111111.t yl11►11 zilllllllll�r `• , �(0)►> 11�11 :�i,`�� a. 11�11 ss �=' 11 11 '� «O)> • g zE b a� W O L . CD �•� w U 20 O COO Cd va l(ti)inrr i.�.l W In yC . s W U ti J G r/ Co� JLLJ J U a C =1v V Q S . LL X p zCD 4 If r • s, W ,.; ry V U . - 11 11 `siil•11 1 scs•' - .+'ari 11 1';Fs;: a`ci�`•11 11 �lc.'0 s - 1"i i's ' �g�.�..:• • •1•. •*c �8.rr.1••1':ri%', <(ON>�'.. Ill,fit 11►1�1111� _ 11►1�11►11. • 1111�1111., �ii'111111�11111I. 11►11(11111 t 11►1111111. t2 1/111 i' 1/1/1 j 1 /1111 ■ d/111 1111 11111 1/111 '..-�A{�' fit•♦ �1A ♦♦ IiJ'A •. ��♦ yV A •.- •�1� A ♦♦ A ♦♦ OA'• ��•t• u � ��t�1 {� 'f)�1.:Aq. '�r��k'U ��.%•r• � k ^ . : •• � ^} ° � �O � ACCORD® CERTIFICATE OF LIABILITY INSURANCE F .ATE(MM/DDIYYYY) `,,./ 06/16/2021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Carlos Teixeira NAME: BNC Insurance Agency PHONE (914)937-1230 1 FAX, (914)937-1124 A/C No Ext: A/C No 90 S Ridge St UL-2 E-MAIL cteixeira@bncagency.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC N Rye Brook NY 10573-2836 INSURER A: Selective Insurance Company of the Southeast 39926 INSURED INSURER B: FARRELL LTD INSURER C: 7 BROOKVALE PL INSURERD: INSURER E: STAMFORD CT 06905-2205 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2142800933 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. IL R Tf INSD WVD TYPE OF INSURANCE POLICY NUMBER MMIDDYIYYYY MMIDDIYYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1.000,000 CLAIMS-MADE Fx_]OCCUR PREMISES Ea occurrence $ 500,000 MED EXP(Any one person) $ 15,000 A Y S 2395975 12/04/2020 12/04/2021 -PERSONAL BADVINJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY ❑JEa LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANYAUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE El E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 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 if more space is required) CERTIFICATE HOLDER LISTED AS ADDITIONAL INSURED AS PER WRITTEN CONTRACT 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 Rye Brook NY 10573 @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD YORK Workers' CERTIFICATE OF STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured Farrell Ltd DBA/TA Farrell Ltd 203-253-9507 21 B High Street 1c.NYS Unemployment Insurance Employer Registration Number of Rye, NY 10580 Insured N/A 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 20-2207750 2.Name and Address of Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) National Liability &Fire Insurance Company Village of Rye Brook 3b.Policy Number of Entity Listed in Box"1 a" 938 King Street N9WC235405 Rye Brook, NY 10573 3c.Policy effective period 05/24/2021 to 05/24/2022 3d.The Proprietor,Partners or Executive Officers are X] included.(Only check box if all partners/officers included) all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box"3"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: Rakesh Gupta (Print name of authorized representative or licensed agent of insurance carrier) r Approved by: _;} ��pl~ 07/29/2021 (T� 1 (Date) Title: Chief Operations Officer Telephone Number of authorized representative or licensed agent of insurance carder: 844-472-0967 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 :7V wl 't a'for, • ' !:=7. � yF•" a •sue:'�� .•? _a t: S'.�'i+_ � ,�� a dw .Woe' v-V AMF- t dict is IA54,1lieu %Nk L-RMIT# 7 P C3�ccD woo SSL2 L 3.5r 75� DATE APPRO 2021 sts ING Wsp TO ,Villa of Rye weak my kc..,Tio ry i, 41, R-F Vl� r� PLAN . ;{ DATE AUG 6 2021 * FILE COPY V�IL BUILDING DEPANRTMENT