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HomeMy WebLinkAboutBP21-202TYPE OF WORK JOB LOCATION . OWNER 0 1 C CONTRACTOR Ef T. COST � ``CO # FdRMairm ��D # FEE DATE INSPECTION RECORD DATE FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING RGH PLUMBING GAS SPRINKLER ELECTRIC �Q LOW -VOLT 13 AS BUILT FINAL INSP z�y1 02 i�ez 0/y)49� oc J x OTHER APPROVALS ARB BOT PS - ZBA OTHER LASS c VILLAGE OF RYE BROOK WESTCHESTER COUNTY, NEW YORK NO: 23-025 Certificate of Occupaucp This is to certify that &Y i C PO) Wzer 4 l.'t ul V eiq of, RLAC Y�� 1 !V T, having duly filed an application on �-hn ucv u c'� / _ 20 J 3 requesting a Certificate of Occupancy for the premises known as, Rye Brook,NY, located in a�( J Zoning District and shown on the most current Tax Map as Section: LQ24 Block: / Lot: aQ , and having fully complied with the requirements of the Building Code and the Zoning Ordinance under Building Permit No. '� , issued V ` 20 c;2 /, 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 �f following New York State Classifications, Use: K- ��' TQ/Y//�U , Construction: 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 exi ilities shall be made,and no enlargement, whether by extending on any side or by increasing in height shal m r shall` building be moved from one location to another until a permit to accomplish such change has been o taine fro he B ding Inspector. Acting Building Inspector,Village of Rye Brook: Date: F EB 13 2023 R ENT For office use only. ECE�WE D BUILD R PERMIT#�?�QR VIL OF RYE OK ISSUED: J A N 2 7 2023 9 8 KING STRE YE BROOK, YORK 10573 DATE: ( — FEE: 105 PAID LLAGE OF RYE BROOK I L D I NG 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: 1 I l Pi✓11 V1n/� ��Gt Occupancy/Use:"kA-P- ✓\C�,Parcel ID#: 3 /0 0Q, f-P►m '(B5'IG�P�'1 A. Zone: Owner:�T�(\L �-��G,v�C Q.►� I�o� 1 Z Address:LA 0�1 f lQf\i wO �G L P.E./R.A. or Contractor: i�d Aw p o0+, 1NI[(1,1 VAddress: Person in responsible charge:LAAXen ktMc Pn1 i I Address: I I M IG+YIL 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,,C"OUNTY OF WESTCHESTER as:IFA _ l IA Lza''I � V©tV 1'K,T (- being duly sworn,deposes and says that he/she resides at LA M'\1��1"V\ P Lp --- (Print Name of Applicant) (No.and Street) in e v\Q- & COY- , t2�] ,in the County of in the State of ,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:$ 3 a-V 0 , for the construction or alteration of ��►-ZZ01-'n 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 Sworn to before me this day of , 20�� day of , 20 Signature of Property Owner Signature of Applicant t Name of Prop�e/rty�Owner Print Name of Applicant Notary Public SHARI MELILLO Notary Public -. pry Public,State of New York 'n.01ME616O063 <iflec in Westchester County 8;t_'!2u21 :is ion Expires January 29,20>_� ti �E 4R��• i O� Zm cu � �9a2 BUILDING DEPARTMENT �,LJ BUILDING INSPECTOR I 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 : (-Yl t ` \y��, `C�4 DATE: - I '0 PERMIT# CT.1 ISSUED: E LOCK:Z� �`�� LOT: LOCATION: C`(Y� OCCUPANCY: Z ❑ 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 `��1� ��C��"'e-P ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CdOSS CONNECTION ,FINAL ❑ OTHER C rl = O = 1 N N l [ E � = a 0o ao � y� M C6 ~ O CPS O co C 0 C4 U v E.., „ W O a gwo F' w 5 F F, O N1-1 O $ Q G F L u_ z a _ U U co _ F= oo O w � o z � , C 01% `n W cec Z a c u , z E- MCI W �, z 'rON r.� O 4,00 ICI O� FiM (s+ V U 4 r r,n L z �I V Y frl p a" gL v, Q�I m 4 CEME BUILDINGZnE-0I'0�AkRkTMENT AUG 16 2021 VIL ,rGE OF RYE 0400K DD 938 ICIN(aTREETRYE 13 ,NY 10573 VILLAGE OF RYE BROOK (914)09-0668 FAQ( 939-5801 BUILDING DEPARTMENT - T - ook org ELECTRICAL PERMIT APPLICATION Westchester County Master Electricians License Required / FOR OFFICE USE ONLY BP#: a o 02 EP#: C:-)L/ a C Approval Date: AUG 17 111 Permit Fee: $ I4JlJ � 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 rdmove 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. 11 1.Address:�—M t I� `�_('e SBL: I e�tl �OS'�^a� Zone: Gb 2.Property Owner: ..lC 17 E Address:�'� i I e n i C) yl lP l a C � Phone#: Cell#: 9 .4-365 l011� email: 3.Master Electrician: bib i o,9 Address: 6 - tom,L Lic.#: q Phone#: - Cell#: 3� `�� 255 2—email: /j Company Name:� � 46 ["j gjc-- L Address: SJ��G1D/Il CZ '&&K 4.Proposed Electrical Work/Fixture Count: = Ef" A/IQ I +S ,---STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: being duly sworn,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 theC /�/�/�/✓ for the legal owner and is duly authorized to make and file this application. (indicat 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 of 20 9�t\ Signature of Property Owner S e of Applicant c� Print Name of Property Owner Name of Applicant Notary Public Notary Public SHARI MELILLO Notary Public,State of New York No.01 ME6160083 Oualified in Westchester County�1 Commission Exoires Janusnp 29 20 OQ3 3/21/19 i- Westchester Rockland Electrical Inspection Services, Inc. Phone: 914-347-3595 DO NOT WRITE HERE-FOR OFFICE USE ONLY ax• 914-347-3596 43 North Lawn Avenue F � �.�, Elmsford, NY 10523 BUILDING PERMIT NO. TEMP# DATE Z�2o�L 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 BUILDING OCCUPANCY OWNER'S NAME AND ADDRESS HOME TELEPHONE NUMBER 1Y/ LJ CURRENT SUPPLIED BY FROM EIR 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. 7-FL. 3' FL. ROOK 'BULDINGIDEPARIMENT REMARKS:LIST OTHER ELECTRICAL DEVICES NOT SET FORTH ABOVE: S . r G 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❑ ADDITIONAL❑ EXPOSED❑ CONCEALED❑ MUST ENTER APPLICANTS IDENTIFICATION NUMBER SERVICE ENTERS BUILDING OVERHEAD❑ UNDERGROUND LI 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 APPLICANT W;Wli7 ADDRM TELEPHONE NO. xf CRY OR POST OFFICE ZIP COUL. LICENSE NO.WHEN APPLICABLE 06y&Ii WESTCHESTER ROCKLAND ELECTRICAL INSPECTION VRE15SERVICES,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: AJ Electric LLC Eric&Lauren Pollitzer 9 Garden Terrace CT, Shelton 06484 Located at:4 Millenium Place Rye Brook, NY 10573 Certificate Number: 1031650 Section: 124.65 Block: 1 Lot:2 BDC: Permit Number:EP:21-201-BP:21-202 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 in/on the premises at: 4 Millenium Place Rye Brook,NY 10573 Basement 11st 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 11/09/21 Name Type Quantity Receptacle GFCI ------- 4 Dimmer 600 wafts ------- 3 Oven Gas or Electric ------- 1 Dishwasher Fixtures Pendant ------- 2 Fixture-Luminaire Recessed ------- 6 This Certificate has been approved by Westchester Rockland Electrical Inspection Services. This certificate may not be altered in any way. G� This certificate is valid for work performed before date of inspection only. 0 h N N p a M Owl o ., , CIA 96 E- a w O o � w to O 0 o W o F W �• c � o V < Q G mw W � O °' N U w � ' <� < o► 9z E••I Z p c i a" Or ol Wo wIA z U A � can., ~ z a v A „Qj = > m ►� r� oo a o wup) Ed ;. z � C. W e g 66 F W � o o � � c w z c 9 ° Q .. a 0. a BUIL E MENT D ECEHF DD VIL E OF Ryt OK AUG 2 2021 938 Knv ` ET RYE B ,NY 10573 (914)9 939-5801 VILLAGE OF RYE BROOK tj org BUILDING DEPARTMENT PLUMBING PERMIT APPLICATION FOR OFFICE USE ONLY BP#: --Ql— PP#: Approval Date: AUG 1 2 qQ21 Permit Fee: $ AD' — 10b Approval Signature: Other: Disapproved: \ (fees are non-refundable) Application dated, S I Q al is hereby made to the Building Inspector of the Village of Rye Brook NY, for the issuance of a Permit to install an 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: H 1A I L LE"l vt.k P LOL07 SBL: ADZ/ eo S_I—a Zone: U� 2.Proposed Work: k.4AL," U,�,1. -t" 3.Property Owner: Ld} ,6tc [v t A T Telt— Address: L\ kAt►.+-,lt-t-Y% C(AkC Phone#: 114 3&� - I O A L' Cell#: 1 email: 5571 4.Master Plumber: n A, C ,'L Address: 57( T,ps f 104 S17 Lic.#: I 5j I Phone#: 1'2— 3`I SIDOL) Cell#:q1 1 3 SQ email: , -k^ '11 L Company Name: rj,. L.2g & (sT Address: ?1 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 j L f 2nd Floor I 1 3 Floor 41 Floor 51'Floor Exterior 5.*List Other Equipment/Provide Details: " l ,.y I .S. (Notarized Signatures Required Next 2 Pages) 3/21/19 D [EC EME BUILD G DEPARTMENT VI E OF RYE OK AUG 2 2021 938 K><Nc ET RYE BR NY 10573 (914)9 �$l 9 39-5801 VILLAGE OF RYE BROOK �G.� 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 NE(W� YORK, COUNTY OF WESTCHESTER ) as:31. �,((V4e c\ Y��� f , residing at, q 1)b\_A-i w lRL{�QI ne I�rwU c T��i IISI-I-) t Print nann:) t \ddrCN'\N here you lip C I �r 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; VA Rye Brook,NY. Further that all statements contained herein are true, and that to the best of his/her knowledge and belief, that there are no known illegal cross-connections concerning either the storm sewer or sanitary sewer, and further that there are no roof drains, sump pumps, or other prohibited stormwater or groundwater connections or sources of inflow or infiltration of any kind into the sanitary sewer from the subject property in accordance with all State, County and Village Codes. 6uVV&1yA yCL12 (tii�naturcofPmhcrt� (� , .. ;_,; (Print Name of Prul)crty(h�ncrl*sl) 2 Sworn to before me this day of /1v , 20 otar� Public) ALEXANDRA H.MARSHALL Notary Public,State of New York No.O1FR6363711 (2) Qualified In Westchester County Commission Expires August 28,20� 3/21/19 This application must be properly completed in its entirety by a N.Y. State Registered Architect or N.Y. State Licensed Professional Engineer&signed by those professionals where indicated. It must also include the notarized signature(s) of the legal owner(s) of the subject property, and the applicant of record in the spaces provided. Any application not properly completed In its entirety and/or not properly signed shall be deemed null and void, and will be returned to the applicant. Please note that application fees are non-refundable. S ATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: being duly sworn,deposes and states that he/she is the applicant above named, (print name of individual signing 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 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. By signing this application, the property owner further declares that he/she has inspected the subject property, and that to the best of his/her knowledge there are no roof drains, sump pumps or other prohibited stormwater or groundwater connections or sources of infiltration into the sanitary sewer system on or from the subject property. 7 Sworn to before me this -> Sworn to before me this �'�)L day of v v. �- , 20_�LL day of l l� , 20 a 1 /y PN� keA Signature of Property Owner Signature of lican 0-L "'4 un lrintJ�e\' L� f 1- Print Name of Property Owner Name of Applicant Public Notary Public SHARI MELILLO ALEXANDRA H.MARSHALL Notary Public,State of New York Notary Public,State of New York No.01 ME6160063 No.OiFR63637:U Oualified in Westchester County Qualified In Westchester county Commission Exoires Januen,29 20 Commission Expires August 28,20 o— (8) 3/21/19 Mike Izzo From: Mike Izzo Sent: Monday, July 18, 2022 1:26 PM To: Eric Pollitzer Cc: Steven Fews; Tara Orlando; Laura Petersen Subject: RE: Pollitzer Permit Extension Dear Mr. Pollitzer, I am pleased to inform you that a six (6) month extension to your open permit#BP21-202 has been approved, and that the new permit expiration date is, February 4, 2023. Please arrange for all work to be completed and successfully inspected, and for all paperwork&fees to be remitted to the Village such to facilitate the issuance of the Certificate of Occupancy/Certificate of Compliance closing out the permit on or before that date. Please note that in accordance with Village Code §250-10.A., it is a violation to use or occupy or to allow the use or occupancy of any building,premises or part thereof without a Certificate of Occupancy duly issued by the Building Inspector. Thank you. Michael J. Izzo Building&Fire Inspector Village of Rye Brook, NY (914)939-0668 Original Message From: Eric Pollitzer <ericpollitzer@gmail.com> Sent: Monday,July 18, 2022 10:57 AM To: Mike Izzo <MIzzo@ryebrook.org> Cc: Steven Fews <SteveFews@ryebrook.org>;Tara Orlando <torlando@ryebrook.org>; Laura Petersen <LPetersen@ryebrook.org> Subject: Re: Pollitzer Permit Mr. Izzo thank's for getting back to me so quickly. Can we request a 6 month extension? At this time the store does not have an estimated ship or delivery date for the oven. Thank you Sent from my Whone > On Jul 18, 2022, at 10:35 AM, Mike Izzo <MIzzo@ryebrook.org> wrote: > Dear Mr. Pollitzer, > Thank you for the email. >According to our records, your permit#BP21-202 won't expire until August 4, 2022. > How long an extension were you requesting? 1 > > Michael J. Izzo > Building&Fire Inspector > Village of Rye Brook,NY > (914)939-0668 > Original Message - > From: Eric Pollitzer <ericpollitzer@gmail.com> > Sent: Thursday,July 14, 2022 9:21 AM > To: Mike Izzo <Mlzzo@ryebrookorg> > Subject: Pollitzer Permit > Hi Mr. Izzo, > Hope all is well. > We have open permit for a kitchen renovation. Our address is 4 Millenium Place. We're waiting on a delivery date for our oven and likely this will not happen prior to the permit expiring. We'd like to request an extension for the permit at this time. > Please let me know if you need any additional information. > Thank you, > Eric Pollitzer > Sent from my Whone z Building Permit Check List&Zoning Analysis Address: Zone:TUl> Use: Z( O Const.Type: Other. Submittal Date: `-� 3 Z l Revisions Submittal Dates: Applicant: =O t, 1­1 Nature of Work. 9�i IZ ►� N�►1�-�`�DV Reviews:ZBA: AUG - 4 2021 pB: BOT: Other: OK ( r ( ) FEES:Filing.�S•� BP• ` 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. Shore 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: -2, Electronic Other. ( ) (vKLicense: `"' Workers Comp: `/ Liability —f—Comp.Waiver. Other. ( ) ( ) CODE 753#: Dated: N/A: (Jr ( ) 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: REQUIRED EXISTING PROPOSED NOTES AUG — 4 2021 Area: Date: Circle: Fronc: Fmnr Sides: >3Mr. Main COP. Accs.Cov Ft.H Sb: Sd.H/Sb: SEA: T�Imo: Ft.Imp Hcig /Stories: notes: a • ys i;, YS� >� ....�j �; .A.l 1.. '.a i a -° site 'r <<.. a X���e.�• Jant"Maisano �%aacirester Cuunh Esacuttse r UirMnr•Consumer Protection oa„ Department of Consumer Protection x Ftome Improvement License M P. HARDWOOD FLOORING INC. y 6 REYNWOOD MANOR < `- =s GREENWICH,CT-06831 � 'this hearse is Issued mt accordance++uh,Xriicle XVI of the Westchester County Consumer Protccn(in code and is alid on q upon prexrncc of the oilicial departmrrt.eal Pr,KN of,m.,cnship or immigration status is not required for issuance of this license NO I OR ITI)FRAI.PURPOSFS � Consr, - �o 0 License\umber yF o DauuCExpiratiun � WC-13182-H02 d +{� 0 08/15/2022 y X op y top�rchester C01 AM .rr. - �� � - t d�Y• r' t.� qq}}'y y'�Y;j't -r ,..n� -ryp��`aQ4. y . �tl. + Ili•. �1�� Y+lI Slti rP fE I u+wwosa Cert ID 856 AC 07/30/2021021ORD CERTIFICATE OF LIABILITY INSURANCE DAT ) /30 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Greenwich Independent Insurance HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 87 Greenwich Ave. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Greenwich CT 06830 (203) 869-0302 (203) 869-3233 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA: Hartford Fire Insurance Com an 19682 M.P Hardwood Flooring Inc. INSURERB: 98 Orchard Street INSURERC: Cos Cob CT 06807 INSURER D INSURER E. COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'L POLICY NUMBER POLICY EFFECTIVE POLICDATEY EXPIRATION LIMITS -Ll&h= TYPE OF INSURANCE GENERAL LIABILITY EACH OCCURRENCE $ 1.000.000 DAMAGE TO RENTED A X COMMERCIAL GENERAL LIABILITY 31SBAPA9730 07/17/2021 07/17/2022 PREMISES Eaoccurence $ 300,000 CLAIMS MADE FxI OCCUR MED EXP(Any one person) $ 10,000 PERSONAL BADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY PRO- LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $(Ea accident) A ANY AUTO 31 SBA PA9730 07/17/2021 07/17/2022 11000,000 ALL OWNED AUTOS BODILY INJURY SCHEDULEDAUTOS (Per person) $ X HIRED AUTOS BODILY INJURY X NON-OWNED AUTOS (Per accident) S PROPERTY DAMAGE S (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ A X OCCUR �CLAIMSMADE 31SBAPA9730 07/17/2021 07/17/2022 AGGREGATE $ 1,000,000 $ DEDUCTIBLE $ Hx RETENTION $ 10,000 $ A WORKERS COMPENSATION AND 31WRCNN1773 07/01/2021 07/01/2022 X TORY WCSTATT OH- S EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $ SOO,OOO ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? I E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 A OTHER 31SBAPA9730 07/17/2021 07/17/2022 Employee Dishonesty - $25,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Job: Eric Pollitzer 4 millennium place Rye Brook NY 10573 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN Village of Rye Brook NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL 938 King Street IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. Rye Brook NY 10573 AUTHORIZED REPRESENTATIVE ACORD 25(2001108) � ©ACORD CORPORATION 1988 PRggellobf12 New Workers' RK STA E Compensation CERTIFICATE OF Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE la. Legal Name and address of Insured(use street address only) 1b. Business Telephone Number of Insured M P HARDWOOD FLOORING INC. 1c. NYS Unemployment Insurance Employer 6 REYNWOOD MNR Registration Number of Insured GREENWICH CT 06831-3145 1d. Federal Employer Identification Number of Insured or Work Location of Insured (Only required if coverage is specifically Social Security Number limited to certain locations in New York State, i.e. a Wrap-Up Policy) 26-2660594 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) Hartford Fire Insurance Company THE VILLAGE OF RYE BROOK 19682 938 KING ST 3b. Policy Number of Entity Listed in Box 1a": RYE BROOK NY 10573 31 WEC NN1773 3c. Policy effective period: 07/01/2021 to 07/01/2022 3d. The Proprietor, Partners or Executive Officers are ❑ 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 "1a" 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 Worker's 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: Danielle Clausen (print name of authorized representative or licensed agent of insurance carrier) C", n Approved by: ),(j;r.tt>�t't..,t"- it_ur..� 07/30/2021 (Signature) (Date) Title: Operations Manager Telephone Number of authorized representative or licensed agent of insurance carrier: (866)467-8730 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) Form WC 88 31 21 F Printed in U.S.A. www.wcb.ny.gov Page 1 of 2 � s w ' w w - ,f GC 111 — `'! ' i k r .r. 0 4p Lee NNW tueo r �