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HomeMy WebLinkAboutRP21-039PERMIT # %� - 3 9 DATE: // �� / pip. �J' SECTION BLOCK LOT TYPE OF WORK �00 � % i✓i� JOB LOCATION ZQ1 C�// OLti'liftv�/ 4PCi✓'CJo- 9109 OWNER Q/ Q/pTS,C� O1 /V I7 /% 40S CONTRACTOR r ✓%©fie C ✓i Z'r/O(��y�78-8�y� EST. COST �9 Q009 FEE �C0 # FEE 4 J i , )6.b DATE TCO # FEE DATE • -i3•i•L'f' FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING RGH PLUMBING GAS SPRINKLER 0 ELECTRIC LOW -VOLT Q ALARM AS BUILT FINAL INSP OTHER APPROVALS ARB BOT PB ZBA OTHER 4R tV 4.�u`1J 4 . 19 VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914)939-0668 Christopher J. Bradbury www.iyebrook.org TRUSTEES ACTING BUILDING & FIRE INSPECTOR Susan R. Epstein Steven E. Fews Stephanie J. Fischer David M.Heiser Salvatore W. Morlino CERTIFICATE OF COMPLIANCE February 1,2023 Gary Karetsky&Holly Karetsky 61 Country Ridge Circle Rye Brook,New York 10573 Re: 61 Country Ridge Circle, Rye Brook,New York 10573 Parcel ID#: 129.74-1-41 Roof Permit#21-039 issued on 8/11/2021 to Re-Roof Existing Building This certifies that the new roof,installed under the above captioned permit has been satisfactorily completed. Sincerely, Steven E. Fews Acting Building& Fire Inspector /to ' � � � r� 1 ��� For office use onl D C �O W LE BUILDIN�, IFATMENT w. LL PERMIT VILLAGE OF RYE $460K ISSUED: //—al/ DEC 2 0 2021 9 8 KING STREET,RYE BROOK,I EW YORK 10573 DATE:1a— O Q) (914)93�-966$ X (0,14)939-5801 FEE: — PAID , VILLAGE OF RYE BROOK o [.or i BUILDiy."= i7EPARTMENT , 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 tswwwwwwwswws+►rr►s+r►sssstttts*s*ssttt+*wwww+ww+►++r►■■r►►ss*sst►sstt►ttttsssttttt►*►*►************tst*st*tss*ss**s+w►ww*www GIt Address: C{ c t/1 f /OS 73 Occupancy/Use: Parcel ID#: O> 9. 7'Ll yy _Zone: --� Owner: bc+i�/ Address: 101 (AWVIAPIIUC14 61 , 1 P.E./R.A. or Contractor: \ Address: Q tF. st . C Sa ' Person in responsible charge: VOW yQ'`f1/ -u I<<\ Address: it JY, . Q vl Ft I 1� 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 ritentioned in accordance with law: STATE OF NEW'gYO11RK,COUNTY OF WESTCHESTER as: being duly sworn,deposes and says that he/she resides at� cm4t( 51 . (Pirint Name of Applicant) "A II �,, (No.and Street) in_ PPLA1/tiy �Q 0 ,in the County of L'I/Q S�C�u S-P V in the State ofA _,that (Cityfrown/tVillage) 4 he/she has supervised the work at the location indicated above,and that the actual total cost of the work,including all site improvements,labor, materials,scaffolding,fixed equipment,professional fees,and including the monetary value of any materials and labor which may have been donated gratis was:S��bU ,,'(a(�1'ol�,� , for the construction or alteration of:� r-ewy Oc4 Ylf,Q t7 o&a4 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 � Swbrn to before me this day of -A , 201, 1 day of J�� �S� , 20_a 4 Signature operty Owner pA ���/// Signature of Applicant0-ift I je,(( P. STATE i� qNKewrier / MNA,p r>�qg Y�IC I = OF NEW YO1 ARY Pi ♦ ���� evwea�rsa2 / \� ��ll,�SStQH IE-0`a 1\"� 3,+I I U �E 4RO ' 19b2• TKO BUILDING DEPARTMENT UILDING 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: a3c) DATE: 1 �3 PERMIT#��" ISSUED: 11 .1 I SECT: _7�LOCK: LOT: LOCATION: �� �v' " ' OCCUPANCY: � 'V ❑ 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 INAL OTHER Perry Verrone, LLC 12 Center Street Pleasantville, NY 10570 info OperQLverroneroofing.com Office: (914)747-7663 Fax: (914)747-7665 License WC 21701 H09 REVISED 8/5/2021 REVISED 8/4/2021 REVISED 7/1/2021 Prepared by Perry Holly&Gary Karetsky 61 Country Ridge Circle Rye Brook, New York 10573 Holly: (914) 494-4459 Karetsky59gmail.com Gary: (914) 319-9109 GarvkaretskyPaol.com PROPOSAL FULL ROOF REMOVAL AND REPLACEMENT • All existing asphalt roofing removed and carted from job site • 5/8-inch plywood on entire field of roof • GAF Weather Watch Ice and Snow barrier installed on all gutter edges,valleys and around skylights (6 feet up) • GAF TIGER PAW paper installed on the entire field of roof • GAF LIFETIME Timberline Architectural HD shingles installed on entire field of roof (CHARCOAL) • GAF Cobra Ridge vent installed on all ridges of roof for attic ventilation • GAF TimberTex hip and ridge shingles installed on all ridges • Aluminum vent pipe boots installed over all vent pipes • Aluminum drip edge flashing installed around entire perimeter of roof Page 1 of 5 Initial & Date: • GAF Weather Blocker starters installed on all perimeter edges • Copper chimney fl4shing fabricated and installed • Village of Rye Brook Building Permit included The price for the aforementioned work,which includes labor and material, totals to the sum of: $20,500.00 PRICES EXPIRE 180 DAYS AFTER ESTIMATE DATE ADDITIONAL WORK OPTIONS Please check appropriate box for desired extra work ❑ Carpentry/handyman work calculated on a time and material basis, said work performed at$90.00 per man/ per hour plus material ❑ Chimney pointing performed for an additional $110.00 per man/per hour plus material ❑ Molding repair6 performed for an additional $110.00 per man/ per hour plus material ❑ Soffit repairs performed for an additional $110.00 per man/ per hour plus material Payment schedule is as follows: 50% 3 Days Prior to Start 95% Due the day of substantial completion 5% Retention may be held for resolution of unresolved issues Any monies not paid as specified above will be subject to accrue interest at a rate of 1.5% monthly, and 18% per annum. All material is guaranteed to be as specified above. All work to be completed in a workmanlike manner according to the standard practices.Any alteration or deviation from the above specification involving extra costs will be executed upon a written change order and will become an extra charge over and above the proposal.All agreements are contingent upon strikes accidents or delays beyond our control. Notices to Owner Right to stop work: If any payment under this agreement is not made when due, Perry Verrone, LLC may suspend work on the job until such time as all payments due have been made. Page 2 of 5 Initial & Date: Notice of Lien: The contractor or subcontractor who performs on the contract and is not paid may have a claim against the owner which may be enforced against the property in accordance with the applicable Lien Laws. Cancellation: The owner has an unconditional right to cancel the contract without penalty until midnight of the third business day after he/she signs the contract. Cancellation must be done by giving Perry Verrone, LLC a written notice indicating the owner's intention not to be bound. Upon cancellation, any property traded in, or payments made under this contract will be returned within 10 business days following the receipt of the cancellation notice by Perry Verrone, LLC. Acceptance of Proposal: I have read the introductory packet along with this document and accept the specified conditions as stated, and the prices associated with such. I understand that upon signing this proposal, all documents presented becomes a binding contract. You are authorized to do the work as outlined. Payment will be made as indicated above. Signature Date Roof Replacement Instructions for Homeowner INSIDE THE HOME 1. Any precious items in the attic can be either moved to a secure place within the attic or covered and secured to protect from the vibration of the roof removal process. 2. Dust and/or sawdust may be generated in the attic due to the roof removal process, securely covering belongings is advised. Clean- up of debris in attic is outside the purview of this contract. Page 3 of 5 Initial & Date: 3. If your home has high hat lights located in the cathedral ceiling, you may want to tape the fixture to the ceiling (construction activity on the roof may cause these to come loose). 4. If you have cathedral ceilings, although it is not common, on occasion, some nails may be prone to "pop"- thus exposing the head of the nail through the sheetrock. This is unfortunate but is not the responsibility of Perry's Roofing. 5. If by chance you have opted for a skylight replacement, please consider that the skylight manufacture dimensions have changed over the course of the years which may alter interior placement of your new skylight. There may be interior trim work required to remedy this condition. This is not part of the roofing contract, but we can give you an estimate for this work. OUTSIDE OF THE HOME 1. Outside your home we make every attempt to ensure that we protect your shrubs and belongings. You can help us by removing smaller objects that you can handle, or that may be valuable, to a secure place. Any larger items, such as picnic tables, our men will move to a secure location and replace upon completion. 2. Let us know if there is a power source outside that we can use. 3. Let us know if there are any special precautions regarding any item, or situation, that we should be aware of outside, prior to starting. Signature Date Page 4 of 5 Initial & Date: NEW Department of Taxation and Finance S T-12 4 YORK New York State and Local Sales and Use Tax STATE Certificate of Capital Improvement (12f15) After this certificate is completed and signed by both the customer and the contractor performing the capital improvement, it must be kept by the contractor. Copies of this certificate must be furnished to all subcontractors on the job and retained as part of their records. Read this form completely before making any entries. This certificate may not be used to purchase building materials exempt from tax. Name of contractor(print or type) Name of customer(print or type) Address(number and street) Address(number and street) City State ZIP code City State ZIP code Sales tax Certificate of Authority number(if any) To be completed by the customer Describe capital improvement to be performed: Project name Street address(where the work is to be performed) City State ZIP code I certify that: • I am the(mark an X in one) ❑ owner ❑ tenant of the real property identified on this form: and • the work described above will result in a capital improvement to the real property as outlined in the instructions of this form, and • this contract(mark an Xin one) ❑ includes ❑ does not include the sale of any items that will not become a permanent part of the real property(for example, a free-standing microwave or washing machine). I understand that: • I will be responsible for any sales tax, interest, and penalty due on the contractor's total charge for tangible personal property and for labor if it is determined that this work does not qualify as a capital improvement; and • I will be required to pay the contractor the appropriate sales tax on tangible personal property(and any associated services)when the property installed by the contractor does not become a permanent part of the real property; and • I will be subject to civil or criminal penalties(or both) under the Tax Law if I issue a false or fraudulent certificate. Signature of customer Title Date To be completed by the contractor I,the contractor. certify that I have entered into a contract to perform the work described by the customer named above. and that I accept this form in good faith. (A copy of the written contract, if any, is attached.) I understand that my failure to collect tax as a result of accepting an improperly completed certificate will make me personally liable for the tax otherwise due, plus penalties and interest. Signature of contractor or officer Title Date This certificate is not valid unless all entries are completed. QuickMeasure 61 Country Ridge Cir, Rye Brook, NY 10573 Roof Reports in Under an Hour July 13, 2020 A N Contents Measurements Overview 1 Roof Area 2,784 sq ft Top View 2 Roof Facets 12 Side Views 3 Predominant Pitch 3 / 12 Lengths 4 Ridges/Hips 88 ft Pitches 5 Valleys 44 ft Areas 6 Rakes 172 ft Summary 7 Eaves 160 ft Materials 8 Bends 22 ft a.• f i y u;, ol .•r 06 46 • • 14 • • ! •tip It lk • C•i olp- + • f r, } t. 1 •'� C_ ^. 777777 �fj�� LE "�` ' '-,tip, t � r '•f• � :a�.� ` � 1 QuickMeasure Lengths Roof Reports in Under an Hour A Flash Step Drip N 44 48 3 1 1 1 1 ■ Bend ■ Eave Hip ■ Rake r Ridge ■ Valley 22 160 6 1 72 82 44 Lengths in feet 61 Country Ridge Cir, Rye Brook, NY 10573 . QuickMeasure Pitches Roof Reports in Under an Hour A N 10 13 13 3 3 7 7 5 0 4 5 3 Pitches in inches per foot © 61 Country Ridge Cir, Rye Brook, NY 10573 . QuickMeasure Areas Roof Reports in Under an Hour A N 19 5 5 66 66 292 279 834 28 381 660 148 Areas in square feet 61 Country Ridge Cir, Rye Brook, NY 10573 QuickMeasure Summary Roof Reports in Under an Hour Pitch 0 3 4 5 7 10 13 Area 28 280 381 1,494 571 19 11 Percent 1% 10% 14% 54% 21% 1% 0% Waste 0% 5% 10% 12% 15% 17% 20% Area 2,784 2,923 3,062 3,118 3,201 3,257 3,340 Squares 28 30 31 32 33 33 34 Roof Area 2,784 sq ff ARoof Facets 12 N Predominant Pitch 3 / 12 Bends 22 ff Eaves 160 ff Hips 6 ff Rakes 172 ff Ridges 82 ff Valleys 44 ff Flash 44 ff Step 48 ff Drip Edge 332 ft Leak Barrier 497 ff Ridge Cap 88 ff Starter 332 ff Parapets 0 ff Notes: 1) Measurements are rounded to the nearest whole number. 2) Rakes are defined as sloped roof edges. 3) Eaves are defined as level roof edges.4) Flashing pertains to level roof edges and excludes valleys.5) Step flashing pertains to sloped roof edges and excludes areas around penetrations.6) Drip edge=eaves+rakes. 7)Waste table excludes additional materials needed for ridges, hips, valleys, etc. U61 Country Ridge Cir, Rye Brook, NY 10573 QuickMeasure Roofing Materials Roof Reports in Under an Hour Waste 0% 10% 15% 20% Timberline Products HDZ, HD, Natural Shadow, American bundle 85 94 98 102 Harvest, Reflector, Royal Sovereign, and Cool Series Starter WeatherBlocker bundle 4 4 4 4 Pro-Start bundle 3 4 4 4 Quick-Start roll 11 12 12 13 Roof Deck Protection Deck-Armor, Tiger Paw, FeltBuster 10 sq roll 3 4 4 4 Shingle-Mate roll 7 8 9 9 VersaShield roll 8 9 10 10 Leak Barrier StormGuard, WeatherWatch 2 sq roll 8 9 9 9 WeatherWatch 1.5 sq roll 10 11 12 12 Ridge Cap Seal-A-Ridge bundle 4 4 5 5 TimberTex bundle 5 5 6 6 Z-Ridge bundle 3 3 4 4 TimberCrest box 5 5 6 6 Ventilation Rigid Vent 3, Snow Country, Snow GAF recommends at least one square foot of attic ventilation Country Advanced, Hip Vent, (evenly split between intake and exhaust) for every 300 square IntakePro, Exhaust Vent (Mesh), feet of attic floor space. Visit the GAF ventilation calculator for RidgeRunner, Master Flow Vents more information at www.gaf.com/ventcalculator. Notes: 1)These approximate quantities are based on estimated measurements and are for guidance purposes only. You should always confirm quantities prior to ordering and ensure you are following local building code requirements. 2) For Timberline, 3 bundles=0.984 squares. 3)Starter=eaves+rakes. 4) Leak barrier=bends+eaves+flashing + hips+rakes+step+valleys. 5) Ridge cap=hips+ridges. Installed coverage will be less and depend on quantity and width of side and end laps. 61 Country Ridge Cir, Rye Brook, NY 10573 Wei�� •;=,'�• \\\\\\\\\\ '\\\ 1111 `111`� �.•�\\ 111`1 •_�. i , = ,TimberIine'HDZ` High •- GAF LAYERLOCK 40 U L f _ 1 _ •.ems �'`� � � ♦ S A�rs��� - �I► w.Cr:i+•.� Jam'.. .f-1f, f v Y.�.�`� �iF�+�`*�k,z�: T.. � �O� "y�,. h'7+��Z a��tt•=a America's -selling shinglegot better! The some shingle you know and love, now • - •ck'" Technolog which powers • widest nailing • -• z • to Timberline° HM'" Shingles Benefits: Product details: ■ LayerLock"Technology—Proprietary durability, strength, and exceptional ,Product/System Specifics technology mechanically fuses the wind uplift performance. ■ Fiberglass asphalt construction ■ Dimensions(approx.):131/4'x 39 3/e" common bond between overlapping ss StainGuard®Algae Protection— (337 x 1.000 mm) shingle layers. ■ Exposure:5%'(143 mm) Helps protect the beauty of your ■ Bundles/Square:3 ■ Up to 99.9%nailing accuracy— roof against unsightly blue-green ■ Pieces/Square:64 The StrikeZone'" nailing area is so algae discoloration. ■ StainGuard'"Algae Protection' ■ Hip/Ridge:TimberTexl:TimberCrest'": easy to hit that q roofer placed 999 se High Performance—Designed Seal-A-Ridge"' Z'Ridge:RidglassQ9 out of 1,000 nails correctly in our test.' with Advanced Protection" Shingle ` Starter:Pro-Start:euickstort', WeotherBlocker" ■ WindProven" Limited Wind Technology. Applicable Standards&Protocols: Warranty—When installed with Seamless compatibility—The new ■ UL Listed to ANSI/UL 790 Class A ■ the required combination of GAF ■ State of Florida approved Accessories,Timberline' HDZ'­ Timberline HDZ' Shingles are com- ■ Classified by UL in accordance with Shingles are eligible for an industry patible with traditional Timberline HDI' ICC-ES AC438 Meets ASTM D7158.Class H Shingles for the same look and feel ■ Meets ASTM D3161,Class F first:a wind warranty with no 2 homeowners and contractors rely Meets ASTM D3018,Type 1 maximum wind speed limitation. on for beauty and endurance.' Meets ASTM D3462' ■ Our legendary Dura Grip" sealant ■ ICC-ES Evaluation Reports ■ Perfect Finishing Touch—For the ESR-1475 and ESR-3267 pairs with the smooth microgranule ■best look, use TimberTex" Premium Meets Texas Department of Insurance surface of the StrikeZone' nailing Requirements Ridge Cap Shingles or TimberCrest" ■ ENERGY STAR`'Certified(White Only) area for fast tack.Then,an asphalt-to Premium SBS-Modified Ridge (U.S.Only):Rated by the CRRC:Can Cap Shingles. asphalt monolithic bond cures for be used to comply with Title 24 cool roof requirements Colors & Availability: Results based on study conducted by Home Innovation Research Lobs, i an independent research labr comparing installation of Timberline HD" Shingles to Timberline"HDZ`Shingles on a 16-square roof deck using standard 4-noil nailing pattern under controlled laboratory conditions. Actual results may wry. '15-year WindProven"limited wind warranty on Timbedine"HDZ'" Shingles requires the use of GAF starter strips,roof deck protection, ridge cap shingles,and leak barrier or attic ventilation.See GAF Roofing • •• System Limited Warranty for complete coverage and restrictions.Visit Biscayne Blue1. Copper Con gaLcorNLRS for qualifying GAF products. 'StainGuard'°algae protection is available only on shingles sold in packages bearing the StamGuardn logo.Products with S1ainGuard' algae protection are covered by a 10-year limited warranty against b lue-green algae discoloration.See GAF Shingle&Accessory Limited I To be ntymixed fored completef.Timberline' coverage and restrictions. 70 'To be mixed on one root.Timberline`HDZ"Shingles and Timberline HD" Driftwood t • Shingles must hove matching 6-digd codes found on the end of the bundle. tin When mixed,always use Timberline HD•installation instructions. 'Periodically tested by independent and internal labs to ensure compliance with ASTM D3462 of time of manufacture. lifetime refers to the length of warranty coverage provided and means as long as the original individual owner(s)of a single-family detached residence[or eligible second owner(s)]owns the property where the qualifying GAF products are installed.For other ownerststructures.Lifetime Mission Brown Oyster Gray Pewter • coverage is not applicable.Lifelime coverage on shingles requires use of GAF Lifetime shingles only.See GAF Shingle&Accessory limited Warranty o for complete coverage and restrictions.Lifetime coverage on shingles andI AL m accessories requires use of any GAF Lifetime Shingle and any 3 qualifying GAF accessories.See GAF Roofing System Limited Warranty for complete coverage and restrictions.Visit gatcom/LRS for qualifying GAF products. z Note:It is difficult to reproduce the color clarity and actual color blendsSunset Brick Williamsourg slat of these products.Before selecting your color,please ask to see several full-site shingles. P r AMERICA N !< c3 womsN's CspioreeAw■w We protect what matters most p •MxywMn k•M1rrl:rxxxcr c H .0 1 X N `y / O I'Cl. cv = LO �.. i H o c .� in O Ln y .t••J � 0 Y C U Q •�� V C o u ' y 1• C!. W wz W n} o .: Quo 6ectio - I p 0 (A J y F r- + . . J y O a W .-= N i O w a 04 Q aCL J ; OZ F / �i C7 U .b 04 IA l DATE(MM/DD/YYYY) ACOR" CERTIFICATE OF LIABILITY INSURANCE Ilkk / 1 8/5/2021 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 Erich Courant& Company PHONE F E-MAIL AX 25 East Spring Valley Ave Suite 270 201-226-1200 ac No):201-226-1201 Maywood NJ 07607 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# License#:BR525310 INSURER A: Evanston Insurance CO 35378 INSURED PERRVER-01 INSURER 8: Perry Verrone LLC 12 Center St INSURER C Pleasantville NY 10570 1 INSURERD: INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER:1679233067 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY ERP LTR POLICY NUMBER MM DD/YYYY MMIDD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY 3AA409339 7/1/2021 7/1/2022 EACH OCCURRENCE $4.000,000 CLAIMS-MADE Fx]OCCUR PREMISES Ea occurrence $100,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $4,000,000 POLICY❑ PRO ❑ LOC PRODUCTS-COMP/OP AGG $4.000,000 PRO- OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY L I $ AUTOS ONLY Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED 7 RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE ❑ N/A 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 $ I i DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Village of Rye Brook 938 King Street AUTHORIZED REPRESENTATIVE Rye Brook NY 10573 �.IJ � ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD yYORK 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 914-867-1747 Perry Verrone LLC DBA Perry's Roofing 1 c.NYS Unemployment Insurance Employer Registration Number of 12 Center Street Pleasantville,NY 10570 Insured Work Location of Insured(Only required if coverage is specifically limited to 1 d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e., a Wrap-Up Policy) Number 26-2754386 2.Name and Address of Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Continental Indemnity Village of Rye Brook 3b.Policy Number of Entity Listed in Box"1 a" 938 King Street 46-884191-14 Rye Brook,NY 10573 3c.Policy effective period 03/01/2021 to 03/01/2022 3d.The Proprietor,Partners or Executive Officers are ❑ Included.(Only check box if all partners/officers included) �X 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: Steven Diamond(President) (Print name of authorized representative or licensed aqent of insurance carrier) Approved by: 08/05/2021 (Signature) (Date) Title: Licensed Insurance Broker Telephone Number of authorized representative or licensed agent of insurance carrier: 516-488-3040 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