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RP21-021
PERMIT # czmJ � % DATE:=�� / EXP: 5 alo a. a SECTION T+ q BLOCK LOT f TYPE OF WORK �! S�/! tl 0'0002 JOB LOCATION e lk e r/ ✓e_ OWNER 1d�Q_e'i r Qr/ 37 S lo41 CONTRACTOR 0� Q ��C''� <2 � r EST. COST V/co # TCO # FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING 0 RGH PLUMBING GAS SPRINKLER 0 ELECTRIC LOW -VOLT Q ALARM AS BUILT M FINAL FEE — FEE 13 �jo'A' FEE DATE INSPECTION RECORp DATE INSP %Q # 5160 c;I 7/ Ys 7a OTHER APPROVALS OTHER VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Paul S.Rosenberg (914)939-0668 Christopher J. Bradbury www jyebrook.org TRUSTEES BUILDING&FIRE Susan R Epstein INSPECTOR Stephanie J. Fischer Michael J.Izzo David M. Heiser Jason A. Klein CERTIFICATE OF COMPLIANCE March 30,2022 Lidia Borsari 18 Berkley Drive Rye Brook, New York 10573 Re: 18 Berkley Drive, Rye Brook,New York 10573 Parcel ID#: 135.34-1-51 Roof Permit#21-021 issued on 5/26/2021 to Re-Roof Existing Building This certifies that the new roof,installed under the above captioned permit has been satisfactorily completed. Sincerely, Michael J. Izzo Building& Fire Inspector /tg U L� R` 1 BUILDI R ' 2 MENT For office use onl— PERMIT# 0ol/ FEB 17 2022 VIL ' OF RYE OK ISSUED: S—olla-3/ 93 DING STREE YE BROOKEVlf PORK 10573 DATE: — a7 a-� a VILLAGE OF RYE BROOK (914)9 9 6$ (_�4)939-5801 FEE: 8 / /p— PAIDJK BUILDING DEPARTMENT �i*iv� ro .or 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 iti###k#i#k####kkk#t###kkkik###ii#lilt#i##it#ii##ittiitii#iii#tt#iiiiiiiitiiii###ii#ti##ik##k###########k#i#k###kti#itiiktiki Address: 18 Berkley Drive Rye Brook, NY 10573 Occupancy/Use: one family residential parcel ID#: 135.34-1-51 Zone: /5 Owner: Denise Borsari Address: 18 Berkley Drive P.E./R.A. or Contractor: Franzoso Contracting, INC Address: 33 Croton Point Avenue Croton on Hudson NY 10520 Person in responsible charge: Peter Klatt/Franzoso Contracting Address: 33 Croton Point Avenue Croton on Hudson NY 10520 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: Peter Klatt being duly sworn,deposes and says that he/she resides at 33 Croton Point Avenue (Print Name of Applicant) (No.and Street) in Croton on Hudson in the County of Westchester in the State of NY that (Citylrown/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:$ 20,054.00 for the construction or alteration of: low slope and sloped roof replacement. 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, i.,a-use or s-,:icture until a Certificate of Gccupancy or Certificate of Contpiiance shaii 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 1" , 20 day of (�.Iyl XA✓`} , 20 Z'Z Signature of Property Owner Signature of Applicant Print Name of Property Own Print Name of Applicant lhw Notary Public Notary Public Richard 0.Lanu Michael Bab* Notary Public,state N.Y. Notary Public,State Of New YOrk321 19 N0.01LA60032 0uMed In Westch-- 2 tro No.01 BA6331102 Contmkst�*��,,.. Feb.23. 0�� Quatifted in Westchester county Commission Expires September 2 2023 �E BRC�v/r o`` tim w � '9a2 BUILDING DEPARTMENT BUILDING INSPECTOR ASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK ❑CODE ENFORCEMENT OFFICER 938 KING STREET • RYE BROOK,NY 10573 (914) 939-0668 FAx (914) 939-5801 www.ryebrook.orS - - - - - - - - - - - -- - - - - - - - INSPECTION REPORT - - - - - - -- - - - - - - - - - - - - ADDRESS :- �/ `j 6 Lk'1.I� `7 T L DATE: - Z PERMIT# y I_X- z I - O7 l ISSUED: Z� (SECT: 1 �� BLOCK: 1 LOT:S� LOCATION: IZ� ` �00 OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... ❑ ACCEPTED ❑ REJECTED/REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ NATURAL GAS ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION [ % FINAL OTHER Work Scope JOB: PRJ#43703:Borsari, Denise:Sloped&Low Sloped Roof Replacement CONTACT: Ms. Denise Borsari, 18 Berkley Drive, Rye Brook, NY 10573 USA PHONE#'S: (914)937-8404 (914)439-1511 Sloped Roof Area Covered in Scope of Work:COMPLETE SLOPED ROOF(EXCEPT REAR LEFT SECTION WHICH WAS DONE BY THE REPAIR DEPT ON OCTOBER 2020). • Install permanent OSHA approved stainless steel single D-Ring fall protection anchor. • Loosen or remove existing gutters and leaders,as necessary. • Remove existing roofing(2 layers)down to the wood deck. • Inspect,remove and replace any damaged or rotten plywood with new comparable thickness CDX plywood sheathing @$100.00 per 4'x8'x 1/2"; @$110.00 per 4'x8'x 5/8"; @$120.00 per 4'x8'x 3/4"sheet installed;only as necessary. • Install GAF®Weather Watch@ leak barrier protection"Ice and Snow Shield"impervious rubber membrane behind gutters on the fascia board,continuing up onto the roof decking 6 feet and lining valleys. • Install all new perimeter drip edge. Color:Brown. • Apply GAF®Breathable Deck-ArmorTm roof deck protection across remaining portions of exposed sheathing, fastened with button type nails. • Install GAF®Pro-Start starter shingles to roof area. • Install GAF®Timberline HDZ with LayerLock technology shingles, Lifetime manufacturer warranted architectural shingles to roof area according to manufacturer's specifications. Color:Williamsburg. • 'Includes a GAF"System Plus"limited warranty which gives you 100%repair coverage for any defect in materials for a full 50 years non-prorated coverage. Also includes a Franzoso Contracting, Inc.25 year workmanship warranty. • Roof to Wall Flashing: • Remove Wood Boards at all roof meets wall locations then cut siding above roof line 5 1/2"and run leak barrier protection up onto wall. Install all new prime painted 1 x6 with a"Z"bend flashing. • Use existing step and apron flashing at roof meets wall locations. • Install TWO(2)Lifetime Vent Pipe Flashing:the Ultimate Pipe Flashing features premium silicone&UV stabilized molded PVC compression collar with Kynar PVDF coated 24 ga.galvanized sheet metal perimeter flashing. • Install new copper chimney flashings/counter-flashings. • Install GAF®Snow CountryTm ridge vent to existing ridge vent opening. • Install GAF®TimberteXTm ridge hips to peaks. • Inspect,remove and replace any rotten or damaged fascia with new 1 x6 primed pine fascia @$7.00, 1 x8 @$9.00, 1x10 @$10.00 or 1x12 @$12.00 per foot installed,only as necessary. • Repitch,rehang or tighten existing gutters. • "NOTE: Remove damaged TV antenna on roof. • Proper disposal of debris;complete site restoration. Low Sloped Roof Area Covered in Scope of Work: LOW SLOPED ROOF PORTIONS OF ROOF. • Remove existing roofing down to the wood deck on the flat roof area. • Broom clean existing flat roof to remove any debris. • Inspect,remove and replace any damaged or rotten plywood with new comparable thickness CDX plywood sheathing @$100.00 per 4'x8'x 1/2"; @$110.00 per 4'x8'x 5/8"; @$120.00 per 4'x8'x 3/4"sheet installed;only as necessary. • Pictures to be taken of roof deck to be given to the homeowner upon completion. • Install:GAF Liberty 2-Ply Roofing System. • Install Self Adhering Base Sheet,mechanically fastening,as needed,to roof deck using button nails. • Install Granulated Top Sheet over applied Base Sheet • '2-Ply System includes 12-year material warranty over approved substrates. • Choice of Color:Williamsburg. • Install new termination bars on parapet wall,as needed. • Install new aluminum roof-to-wall flashing and counter flashing. • Install new Drip Edge and Gravel Stop. Color:Brown. • Inspect,remove and replace any rotten or damaged fascia with new 1x6 primed pine fascia @$7.00, 1x8 @$9.00, 1 x10 @$10.00 or 1x12 @$12.00 per foot installed,only as necessary. • Proper disposal of debris;complete site restoration. Printed 04/13/2021 Franzoso Contracting, Inc. 33 Croton Point Ave R)kN OS Croton On Hudson, 10520 F 0 • (914) 271-4572 CON-MAC-VINC, INCO • :.. . www.franzoso.com `•�t Y a :3.!.1� _ ,�. ��'. � e� V. x TruDefinitionR TOTAL R ._ DURATION SHINGLES ROOFING SYSTEM with SureNail" Technology f. ANN moo aM/ - stirs.. dW is dW -� r.rrw ��ir.'�rs�� Pow WM moo 1 Mt. I�� Suers SW 1� i'r � 10 10 go- �#/� r♦ tme om+" In l h � 4 TruDefinition® Duration®Shingles are a component of the Owens Corning'Total Protection Roofing System 1A w- TruDefinition" DURATION SHINGLES with SureNail` Technology Bold contrast. Deep dimension. TruDefinition: TruDefinition Duration®Shingles are . The SureNail' Difference— specially formulated to provide great A technological breakthrough ' contrast and dimension to any roof. SureNal� in roofing.The innovative h Through the use of multiple granule colors and features of Owens Corning'TruDefinition® I"' ! shadowing,TruDefinition® Duration®Shingles Duration® Shingles with patented SureNail® offer a truly unique and dramatic effect.This Technology offer the following; exclusive combination of color and depth is Breakthrough Design.Featuring a tough, what makes TruDefinition®Duration®Shingles woven engineered reinforcing fabric to deliver like no other. consistent fastening during installation. TruDefinition®Duration®Shingles are available Triple Layer Protection: A unique"triple layer" in popular colors with bold, lively contrast of reinforcement occurs when the fabric overlays owa and complementing shadow lines for greater the common bond of the shingle laminate layers dimension.They feature a Limited Lifetime that offers excellent fastener holding power. Warranty"'(for as long as you own your home), 130-MPH Wind Resistance Limited Superior Adhesion.Our enhanced Tru-Bond®' Warranty'and an Algae Resistance Limited sealant grips tightly to the engineered fabric w Warranty.' Beyond the outstanding curb nailing strip on the shingle below. appeal and impressive warranty coverage, Excellent Adhesive Power.Specially formulated, they also come with the advanced performance wide adhesive bands help keep shingle layers of patented SureNail®Technology. laminated together. Exceptional Wind Resistance.Engineered to deliver 130-MPH'wind warranty performance with only 4 nails.Fewer nails required can mean fewer deck penetrations. r _ 1 SureNail"Reinforcing =�-���`_ ■ Woven Fabric Nailing Area Excellent Adhesive i ,l`,i Power i 1 Enhanced Tru-Bond"Sealant «' Triple layer Y'4 Protection`+' "1199;aa, COLORS AVAILABLE IN ALL SERVICE AREAS — see map below r .I � y 47f Amber, Desr,rt Tan Brownwoodt Quarry Grayt Sierra Grayt Shasta Whitet 3 ' Atli- lic s •.� S1` ram[ y�. � �jf' i Y 'i 7 �l IN .••i� t ly r i�yt 1�+•;_♦ s` �ayay7yl�• ! fi �tf'�jp .y'r'4)��.,�,�`•� �- +i a �rd �F �k.. n..ma's F++`r�s.+.�S • yy t {.•.�? 13`,y,`�K.. �*r•��R,:f,-.t'J�:i.1• L'n}1y `.a./�iy�4+1, ��~+'��..�. • . 9 I� ENERGY STARK IS FOR ROOFS TOO Similar to the energy-efficient appliances in your home,roofing products can provide energy- saving qualities. Owens CorningTM ENERGY STARO-qualified shingles can help reduce your energy bills when installed properly. These shingles reflect solar energy, decreasing the amount of heat transferred to a home's interior— and the amount of air conditioning needed to keep it comfortable.Actual savings will vary based on geographic location and individual building characteristics. Call 1-800-GET-PINK' or 1-888-STAR-YES for more information. Product Attributes Warranty Length* Limited Lifetime'(for as long as you own your home) Wind Resistance Limited Warranty* 130- 130 MPH Algae Resistance Limited Warranty* 10 Years TruPROtection" Non-Prorated Limited Warranty* Period 10 Years TruDefinition R Duration' Shingles Product Specifications Nominal Size 13T�<" x 3918" Exposure 5sre" Shingles per Square 64 Bundles per Square 3 Coverage per Square 98.4 sq. ft. Applicable Standards and Codes ASTM D228 ASTM D3018(Type 1) ASTM D3462 ASTM D3161 (Class F Wind Resistance) ASTM D7158(Class H Wind Resistance) ASTM E108/UL 790(Class A Fire Resistance) ICC-ES AC438" UL ER2453-01*" Shasta White color meets ENERGY STAR®requirements for initial solar reflectance of 0.25 and 3-year aged solar reflectance of 0.15; 2013 California Building Energy Efficiency Standards,Title 24,Part 6 requirements;rated by the Cool Roof Rating Council(CRRC). *See actual warranty for complete details,limitations and requirements. **2013 Rooting Homeowner Brand Awareness Study by Owens Corning Roofing and Asphalt,LLC. t Owens Corning Roofing strives to accurately reproduce photographs of shingles.Due to manufacturing variances,the limitations of the printing process and the variations in natural lighting,actual shingle colors and granule blends may vary from the photo.The pitch of your roof can also impact how a shingle looks on your home.We suggest that you view a roofing display or several shingles to get a better idea of the actual color.To accurately judge your shingle and color choice,we recommend that you view it on an actual roof with a pitch similar to your own roof prior to making your final selection. Color availability subject to change without notice.Ask your professional roofing contractor for samples of colors available in your area t t This illustration depicts Triple Layer ProtectiW and the amount of Triple Layer Protection°may vary on a shingle-to-shingle basis. $Tru-Bond"is a proprietary premium weathering-grade asphalt sealant that is blended by Owens Corning Roofing and Asphalt LLC. $$40-Year Limited Warranty on commercial projects. Owens Corning"'Roofing Preferred Contractors are independent contractors and are neither affiliates nor agents of Owens Corning Roofing and Asphalt LLC,or its affiliated companies. SureNail"Technology U.S.Patent 7,836,654 and other patents pending. ENERGY STAR and the ENERGY STAR mark are registered trademarks of the U.S.Environmental Protection Agency. M International Code Council Evaluation Services Acceptance Criteria for Alternative Asphalt Shingles. MM Underwriters Laboratories Evaluation Service Evaluation Report A Excludes non-Owens Corning'"roofing products such as flashing,fasteners and wood decking. r r T ) i 40 A.y i w HOME SWEET HOME •h Your home is your sanctuary.It's the place Together we can make this a positive where you want to feel the most comfortable. experience—an opportunity,really.This is Safe.Protected.But no matter how much you your chance to choose a roof that not only r love your house,it seems the work is never has outstanding performance,but also has completely done.And if purchasing a new exceptional beauty.So for years to come,you'll j roof is on your to-do list,it may seem like feel great every time you pull in the driveway. 71 a daunting task—especially if your roof is Protected. Proud. Home. already damaged or leaking.Since a roof plays such an important role in protecting you and your family from the elements,you realize that _ you can't let the damage get out of hand. Don't worry,we know that a roof replacement ..� project is a big,important decision.You can _ feel confident about choosing our roofing products—Owens Corning has been a recognized leader in the building industry for over 75 years.In fact,we're America's#t roofing brand" Not only can we help you choose the right shingle and roofing system components,we can also help you select the right contractor for the job—an Owens Corning' Roofing Preferred Contractor. f: >i O O n TOTAL The Total Protection Roofing SY stemTMA F ' •_ Working together to help protect and enhance your home. R,0'oFING1JSySTElM It takes more than just shingles to protect your home.It takes an integrated system of components and layers designed to withstand the forces of nature outside while controlling temperature and humidity inside. The Owens Corning'Total Protection Roofing System '^gives you the assurance that all of your Owens Corning'roofing components are working together to help increase the performance of your roof—and to enhance the comfort and enjoyment of those who live beneath it. O Owens Corning-Hip&Ridge Shingles> OVentSurex Exhaust Ventilation Products ©Owens Corning—Shingles • 0 Owens Corning-Starter Shingle Products ©Owens Corning Underlayment Products j © WeatherLock"Self-sealing Ice &Water Barrier Products OVentSure"Soffit or InFlow"Intake Ventilation Products F� • • � I f yy Optional Owens Corning—products designed to support the Total Protection Roofing SystemT"^ PINK"Fiberglas-Blown-In Insulation Illuminator"Tube Skylight raft-R-mate"'Attic Rafter Vent ^Excludes non-Owens Corning'roofing products such as flashing,fasteners and wood decking. © © © O O Help protect against Help protect vulnerable Help prevent damage Enjoy clean lines and Choose from a variety Help protect your roof Help protect the heat and moisture areas where water can from wind-driven rain faster,easier installation of durable styles and against premature ridge vent and add an buildup by creating a do the most damage: by providing an by eliminating the need colors that provide the failure by allowing heat attractive,finished look balanced flow of air eaves,valleys,dormers additional layer of to cut shingle tabs. first line of defense and moisture to escape to your entire roof. through your attic. and skylights. protection between the against the elements. from the attic. shingles and roof deck. OWENS CORNING ROOFING AND ASPHALT, LLC !=' ONE OWENS CORNING PARKWAY TOLEDO,OHIO,USA 43659 • • 1-800-GET-PINKO www.owenscorning.com/roofing Pub.No.10013980-E.Printed in U.S.A.May 2014.THE PINK PANTHER"& ©1964-2014 Metro-Goldwyn-Mayer Studios Inc.All Rights Reserved.The color PINK is a registered trademark of Owens Corning.©20140wens Corning. All Rights Reserved. (Brookville,Kearny,Medina,Minneapolis,Summit) OWENS ' • CORNING Six Attractive, Popular Colors i�'�ir�t- r•75.E •Lr,�•�i'Z�"�}-N - ,:C. ���,��'� � ✓.l4rt. 5;c %�F`Y' '� .,p_ ti .ra;i^ .!�'b���a.,�`?J��.s+a'�1;1~?�'•'� .+e'��, _ � `•- �.,r,• '."ty(•� �� �. •a r j, �r ,���'�^Y'g`,�'{r� Y��.!� .4 4 nth �ytf�'w �ifl.'_ ^y�F r-t. •^ 'i+[�._ k'�,y.. �� � i-� �Ry�".'`�ya'�.''�• `�',�' -,fit' '�� � �� � .� fish ,. rs •.,. , ��,•4r• � -e�. ;' ', �� .• �'�r ii K ,tom :w sR:� !i sM� �rY�w Why DeckSeal is the Preferred Choice Product Attributes Warranty Features Benefits Le Limited warranty—against material defects for up to 15 years • A Dual Compound Formula • Excellent adhesion, to meet the performance handling,and long term The versatile DeckSeal Roofing System can be applied as either a needs of different layers: performance 2 or 3 ply system providing excellent protection to meet a range of • Top coat compound customer needs. provides excellent • Excellent wind uplift granule adhesion characteristics • Back coat compound DeckSeal SA DeckSeal SA provides aggressive SBS Cap SBS Cap adhesion to the -— —— -_— - substrate DeckSeal SA DeckSeal SA DeckSeal SA DeckSeal SA SBS Cap SBS Cap Base/Ply Base/Ply • Granule-free adhesive • Fast tack and reliable selvedge on both the side seam adhesion DeckSeal MA DeckSeal SA DeckSeal MA DeckSeal SA and end laps NailBase Base/Ply NailBase Base/Ply • Attractive colors • Color coordinated roof that complement elements to provide a Product Specifications popular shingle offerings "finished" look for the roof DeckSeal SA SBS Cap*(self-adhered) • Most trusted brand`in • Peace of mind that residential roofing Owens Corning offers Roll Dimension 32' 10"x 39 3/8" (1 OM x 1 M) warranties"on shingles Roll Thickness 130 mills (3.3 MM) and low slope roofing components Roll weight 87 lbs. (39.5 kg) Roll Size(Nominal) 100 sq.ft. Example of 3 Ply System DeckSeal SA Base/Ply$(self-adhered) Roll Dimension 65'8"x 39 3/8" (20M x 1 M) Roll Thickness 80 mils (2.0 MM) Roll weight 95 lbs. (43.1 kg.) .a Roll Size(Nominal) 200 sq.ft. DeckSeal MA NailBase$ Roll Dimension 65'8"x 39 3/8" (20M x 1 M) Roll Thickness 80 mils (2.0 MM) Roll weight 96 lbs. (43.5 kg.) Roll Size(Nominal) 200 sq.ft. Applicable Standards and Codes UL Classifed for use in Class A, B or C roofs as listed in the UL "Roof Materials And Systems Directory" TDI Listed for Usage in Texas Coastal Regions DeckSeal DeckSeal DeckSeal 0 SA SBS Cap SA Base/Ply MA NailBase O 0 0 2016 Roofing Homeowner Brand Awareness Survey by Owens Corning Roofing and Asphalt,LLC. See actual warranty for complete details,limitations and requirements. OWENS CORNING ROOFING AND ASPHALT,LLC t Actual colors and granule blends may vary from the ONE OWENS CORNING PARKWAY photo.We suggest that you view actual product on the TOLEDO,OHIO,USA 43659 roof to get a better idea of the finished color.Color • ® 1-800-GET-PINK® availability subject to change without notice. www.owen morning.com/roofing ft DeckSeal self-adhered roofing system components are designed to be installed on roof slopes between 1/4:12 to 2:12. Pub.No.10020136-A.Printed in U.S.A.June 2016.THE PINK PANTHER"& ©1964-2016 Metro-Goldwyn-Mayer Studios Inc.All Rights Reserved.The #Available in fire-resistant(FR)versions.Visit www.owenscorning.com color PINK is a registered trademark of0wens Corning.@20160wens Corning. for product specification data sheets applicable to these products. All Rights Reserved. (Compton,Portland,Denver,Kearny,Medina,Minneapolis,Summit,Brookville) R [SCENE POWER OF ATTORNEY MAY 2 6 2021 ID NEW YORK STATUTORY SHORT FORM VILLAGE OF RYE BROOK (a) CAUTION TO THE PRINCIPAL: Your Power of Attorney is an important d cuMRtDfR��PARTM NT "principal," you give the person whom you choose (your"agent") authority to sp or dispose of your property during your lifetime without telling you. You do not lose your authority to act even though you have given your agent similar authority. When your agent exercises this authority, he or she must act according to any instructions you have provided or,where there are no specific instructions, in your best interest. "Important Information for the Agent" at the end of this document describes your agent's responsibilities. Your agent can act on your behalf only after signing the Power of Attorney before a notary public. You can request information from your agent at any time. If you are revoking a prior Power of Attorney,you should provide written notice of the revocation to your prior agent(s)and to any third parties who may have acted upon it, including the financial institutions where your accounts are located. You can revoke or terminate your Power of Attorney at any time for any reason as long as you are of sound mind. If you are no longer of sound mind, a court can remove an agent for acting improperly. Your agent cannot make health care decisions for you. You may execute a "Health Care Proxy" to do this. The law governing Powers of Attorney is contained in the New York General Obligations Law, Article 5,Title 15. This law is available at a law library, or online through the New York State Senate or Assembly websites,www.senate.state.ny.us or www.assembly.state.ny.us. If there is anything about this document that you do not understand, you should ask a lawyer of your own choosing to explain it to you. (b) DESIGNATION OF AGENT(S): I, Lidia Borsari 18 Berkley Drive, Rye Brook, NY 10573 (name of principal) (address of principal) hereby appoint: Victor Borsari 18 Berkley Drive, Rye Brook, NY 10573 (name of agent) (address of agent) Denise Borsari 18 Berkley Drive, Rye Brook, NY 10573 (name of second agent) (address of second agent) as my agent(s). If you designate more than one agent above, they must act together unless you initial the statement below. & My agents may act SEPARATELY. 2010 N.Y.Laws ch.340 Page 1 of 9 (c) DESIGNATION OF SUCCESSOR AGENT(S): (OPTIONAL) If any agent designated above is unable or unwilling to serve, I appoint as my successor agent(s): (name of successor agent) (address of successor agent) (name of second successor agent), (address of second successor agent) Successor agents designated above must act together unless you initial the statement below. ( ) My successor agents may act SEPARATELY. You may provide for specific succession rules in this section. Insert specific succession provisions here: (d) This POWER OF ATTORNEY shall not be affected by my subsequent incapacity unless I have stated otherwise below, under"Modifications". (e) This POWER OF ATTORNEY DOES NOT REVOKE any Powers of Attorney previously executed by me unless I have stated otherwise below, under"Modifications". If you do NOT intend to revoke your prior Powers of Attorney, and if you have granted the same authority in this Power of Attorney as you granted to another agent in a prior Power of Attorney, each agent can act separately unless you indicate under"Modifications"that the agents with the same authority are to act together. (f) GRANT OF AUTHORITY: To grant your agent some or all of the authority below, either (1) Initial the bracket at each authority you grant, or (2) Write or type the letters for each authority you grant on the blank line at(P), and initial the bracket at(P). If you initial (P), you do not need to initial the other lines. I grant authority to my agent(s)with respect to the following subjects as defined in sections 5-1502A through 5-1502N of the New York General Obligations Law: ( ) (A) real estate transactions; ( ) (B)chattel and goods transactions; ( ) (C) bond, share, and commodity transactions; (� (D) banking transactions, ( ) (E) business operating transactions; (� (F) insurance transactions; ( ) (G) estate transactions; ( ) (H)claims and litigation; Page 2 of 9 2010 N.Y.Laws ch.340 ( ) (1) personal and family maintenance: If you grant your agent this authority, it will allow the agent to make gifts that you customarily have made to individuals, including the agent, and charitable organizations. The total amount of all such gifts in any one calendar year cannot exceed five hundred dollars; ( ) (J) benefits from governmental programs or civil or military service; ( ) (K) health care billing and payment matters; records, reports, and statements; ( ) (L) retirement benefit transactions; ( ) (M)tax matters; ( ) (N) all other matters, ( ) (0)full and unqualified authority to my agent(s)to delegate any or all of the foregoing powers to any person or persons whom my agent(s) select; ( ) (P) EACH of the matters identified by the following letters: A, B, C, D, E, F, G, H, I, J, K, L, M, N, 0 and P. You need not initial the other lines if you initial line (P). (g) MODIFICATIONS: (OPTIONAL) In this section, you may make additional provisions, including language to limit or supplement authority granted to your agent. However, you cannot use this Modifications section to grant your agent authority to make gifts or changes to interests in your property. If you wish to grant your agent such authority, you MUST complete the Statutory Gifts Rider. bu Initial here to grant authority to all of the following powers labeled 1 through 22, inclusive. 1. Deal with tax authorities, to execute and sign on my behalf any and all Federal, state, local and foreign income and gift tax returns, including estimated returns and Interest, dividends, gains and transfer returns, for all periods between 1950 and 2050, and to pay any taxes, penalties and interest due thereon; to allocate generation- skipping transfer tax exemptions (within the meaning of Section 2642(a) of the Internal Revenue Code) and to make tax elections; to represent me or to sign an Internal Revenue Service Form 2848 (Power of Attorney or Declaration of Representative)or Form 8821 (Tax Information Authorization), or comparable authorization, appointing a qualified lawyer, certified public accountant or enrolled agent(including my attorney-in-fact if so qualified)to represent me before any office of the Internal Revenue Service or any state, local or foreign taxing authority with respect to the types of taxes and years referred to above, and to specify on said authorization said types of taxes and years; to receive from or inspect confidential information in any office of the Internal Revenue Service or state, local or foreign tax authority; to receive and deposit, in any one of my bank accounts, or those of any revocable trust of mine, checks in payment of any refund of Federal, state, local or foreign taxes, penalties and interest; to pay by check drawn on any bank account of mine or of any revocable trust of mine and have accounts to permit my attomey-in-fact to draw checks for payment of said items; to execute waivers (and offers of waivers) of restrictions on assessment or collection of deficiencies in taxes and waivers of notice of disallowance of a claim for credit or refund;to execute consents extending the statutory period for assessment or collection of such taxes; to execute offers in compromise and closing Agreements under Section 7121 or comparable provisions of the Internal Revenue Code or any Federal, state, local or foreign tax statutes or regulations; to delegate authority or to substitute another representative for any one previously appointed by me or my attorney-in-fact; and to receive copies of all notices and other written communications involving my Federal, state, local or foreign taxes at such address as my attorney-in-fact may designate. 2. Make voluntary contributions to, transfer assets between, and withdraw amounts from any qualified retirement benefit plan or IRA; to make elections with respect to the timing, method and amounts of withdrawals, distributions and/or rollovers, methods of calculating minimum required distributions, and methods of distribution as Page 3 of 9 2010 N.Y.Laws ch.340 a beneficiary of another's plan or IRA; and to take any other actions with respect to any such plan or IRA as I could take. 3. Apply for government and insurance benefits on my behalf. 4. Establish accounts of all kinds (including checking and savings accounts)for me with banks, savings & loan institutions, and other financial institutions of any kind. 5. Write checks on or to withdraw from and grant security interest in all accounts in my name or in which I am an authorized signatory (except accounts which I hold in a fiduciary capacity);to deposit into, or modify, close, or otherwise prepare any instrument affecting those accounts or items. 6. Real estate transactions, including all fixtures and articles of personalty therein. 7. Insurance transactions, including borrowing from transferring ownership, or surrendering the policies. 8. Estate transactions, including waiver and consents. 9. Create,fund, amend, add to or terminate revocable or irrevocable intervivos trusts. 10. Accept transfers or distributions from any trustee of any trust. 11. Enter any safe deposit box or other place of safekeeping standing in my name alone or jointly with another and to remove the contents and to make additions, substitutions or replacements. 12. Complete charitable pledges. 13. Make statutory elections and renounce or disclaim any interest by testate or intestate succession or by inter vivos transfer consistent with paragraph (c) of section 2-1.11 of the New York Estates, Powers and Trusts Law. 14. Enter into buy/sell agreements. 15. All dealings in respect to loans and forgiveness of debts. 16. Social Security Administration, Veterans Administration, Social Services, Medicaid and all other government benefits or entitlements, including claims, planning for eligibility, submission of applications and appeals. 17. Have access to and disclose medical records and other personal information. 18. Reimburse my agent under a Health Care Proxy for any costs (including legal fees) reasonably incurred in or as a result of acting pursuant to such Proxy. 19. Retain, discharge and pay for the services of attorneys, accountants,financial partners, geriatric care managers, social workers and other health care professionals. 20. Draw, accept, endorse or otherwise deal with any checks or other commercial or mercantile instruments, including the right to make withdrawals from any savings account or other accounts. Page 4 of 9 2010 N.Y.Laws ch.340 21. Borrow money on such terms and with such security as my attomey(s)-in-fact may decide in his sole discretion and to execute all notes, mortgages and other instruments relating to such. 22. Power and authority to serve as my personal representative for all purposes of the Health Insurance Portability and Accountability Act of 1996 (Pub L. 104-191, 45 CFR160-64), or any similar or successor statute, including, but not limited to, access to all medical information and files, as well as all financial and insurance information with regard to any medical records. (h) CERTAIN GIFT TRANSACTIONS: STATUTORY GIFTS RIDER(OPTIONAL) In order to authorize your agent to make gifts in excess of an annual total of$500 for all gifts described in (1)of the grant of authority section of this document(under personal and family maintenance), you must initial the statement below and execute a Statutory Gifts Rider at the same time as this instrument. Initialing the statement below by itself does not authorize your agent to make gifts. The preparation of the Statutory Gifts Rider should be supervised by a lawyer. &—) (SGR) I grant my agent authority to make gifts in accordance with the terms and conditions of the Statutory Gifts Rider that supplements this Statutory Power of Attorney. (i) DESIGNATION OF MONITOR(S): (OPTIONAL) If you wish to appoint monitor(s), initial and fill in the section below: ( ) I wish to designate , whose address(es) is (are) as monitor(s). Upon the request of the monitor(s), my agent(s) must provide the monitor(s) with a copy of the power of attorney and a record of all transactions done or made on my behalf. Third parties holding records of such transactions shall provide the records to the monitor(s) upon request. (j) COMPENSATION OF AGENT(S): (OPTIONAL) Your agent is entitled to be reimbursed from your assets for reasonable expenses incurred on your behalf. If you ALSO wish your agent(s) to be compensated from your assets for services rendered on your behalf, initial the statement below. If you wish to define "reasonable compensation", you may do so above, under "Modifications". ( ) My agent(s) shall be entitled to reasonable compensation for services rendered. (k) ACCEPTANCE BY THIRD PARTIES: I agree to indemnify the third party for any claims that may arise against the third party because of reliance on this Power of Attorney. I understand that any termination of this Power of Attorney, whether the result of my revocation of the Power of Attorney or otherwise, is not effective as to a third party until the third party has actual notice or knowledge of the termination. (1) TERMINATION: This Power of Attorney continues until I revoke it or it is terminated by my death or other event described in section 5-1511 of the General Obligations Law. Section 5-1511 of the General Obligations Law describes the manner in which you may revoke your Power of Attorney, and the events which terminate the Power of Attorney. 2010 N.Y.Laws ch.340 Page 5 of 9 (m) SIGNATURE AND ACKNOWLEDGMENT: In Witness Whereof I have hereunto signed my name on the day of June, 2017 PRINCIPAL signs here: STATE OF NEW YORK ) ss: COUNTY OF WESTCHESTER ) On the 27'day of June, 2017, before me, the undersigned, personally appeared Lidia Borsari, personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her capacity, and that by his/her signature on the instrument, the individual, or the person upon behalf of which the individual acted, executed the instrument. Notary Public Andrea M.Deg WWM Notary pµbK Stale of New York No.020M72267 Quwffiod in w6whoper comtY Commission Expires NO nber 12 011-,d a Page 6 of 9 2010 N.Y.Laws ch.340 (n) IMPORTANT INFORMATION FOR THE AGENT: When you accept the authority granted under this Power of Attorney, a special legal relationship is created between you and the principal. This relationship imposes on you legal responsibilities that continue until you resign or the Power of Attorney is terminated or revoked. You must: (1) act according to any instructions from the principal, or, where there are no instructions, in the principal's best interest; (2) avoid conflicts that would impair your ability to act in the principal's best interest; (3) keep the principal's property separate and distinct from any assets you own or control, unless otherwise permitted by law; (4) keep a record or all receipts, payments, and transactions conducted for the principal; and (5) disclose your identity as an agent whenever you act for the principal by writing or printing the principal's name and signing your own name as "agent" in either of the following manners: (Principal's Name) by (Your Signature) as Agent, or(your signature) as Agent for(Principal's Name). You may not use the principal's assets to benefit yourself or anyone else or make gifts to yourself or anyone else unless the principal has specifically granted you that authority in this document, which is either a Statutory Gifts Rider attached to a Statutory Short Form Power of Attorney or a Non-Statutory Power of Attorney. If you have that authority, you must act according to any instructions of the principal or, where there are no such instructions, in the principal's best interest. You may resign by giving written notice to the principal and to any co-agent, successor agent, monitor if one has been named in this document, or the principal's guardian if one has been appointed. If there is anything about this document or your responsibilities that you do not understand, you should seek legal advice. Liability of agent: The meaning of the authority given to you is defined in New York's General Obligations Law, Article 5, Title 15. If it is found that you have violated the law or acted outside the authority granted to you in the Power of Attorney, you may be liable under the law for your violation. (o) AGENT'S SIGNATURE AND ACKNOWLEDGMENT OF APPOINTMENT: It is not required that the principal and the agent(s) sign at the same time, nor that multiple agents sign at the same time. I/we,Victor Borsari and Denise Borsari, have read the foregoing Power of Attorney. I am/we are the person(s) identified therein as agent(s)for the principal named therein. I/we acknowledge my/our legal responsibilities. Agent(s) sign(s) here: _ r 2010 N.Y.Laws ch.340 Page 7 of 9 STATE OF NEW YORK ) ss: COUNTY OF WESTCHESTER ) On the 27`h day of June, 2017, before me, the undersigned, personally appeared Victor Borsari and Denise Borsari, personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her capacity, and that by his/her signature on the instrument, the individual, or the person upon behalf of which the individual acted, executed the instrument. Notary Public Page 8 of 9 2010 N.Y.Laws ch.340 M:1DPWard DocumentslEslate Plannirgl6orsari,Victor&UdialLidia GW Extended Statutory POA 2010.wpd (p)SUCCESSOR AGENT'S SIGNATURE AND ACKNOWLEDGMENT OF APPOINTMENT: It is not required that the principal and the SUCCESSOR agent(s), if any, sign at the same time, nor that multiple SUCCESSOR agents sign at the same time. Furthermore, successor agents can not use this power of attorney unless the agent(s) designated above is/are unable or unwilling to serve. I/we, , have read the foregoing Power of Attorney. I am/we are the person(s) identified therein as SUCCESSOR agent(s)for the principal named therein. Successor Agent(s) sign(s) here: STATE OF NEW YORK ) ss: COUNTY OF ) On the day of , 2017, before me, the undersigned, personally appeared , personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her capacity, and that by his/her signature on the instrument,the individual, or the person upon behalf of which the individual acted, executed the instrument. Notary Public 2010 N.V.Laws ch.340 Page 9 of 9 MADPWard DocumentslEstate PlanninglBorsari,Victor&LidiaUAia GW Extended Statutory 130A 2010.wpd FRANZOSO �, CONTRACTING n,EMBER "We Have a Showroom in Every Neighborhood" • �� � '• www.tianzoso.com Member Since 2006 33 Croton Point Avenue*Croton on Hudson,New York 10520 *(914) 271-4572 Mark Franzoso.President Westchester:WC-01795-H88/Putnam:PC-375/Yonkers:1325/Rockland: H-09940- B6-00-00/CT:HIC.0632079 IRI L February 4, 2022 FEB 1 7 2022 RE: Building Permit Close Out Do VILLAGE OF RYE BROOK BUILDING DEPARTMENT Dear Ms. Borsari, This letter is to help assist you in closing out your building permit. Enclosed please find an application for certificate of occupancy. This form musd by the homeowner and notarized. The building department will also require a 110.QCC heck made out to "the Village nf-R_ye gook"this is the fee to close out the permit and receive your certificate of completion. These forms and check must be dropped off or mailed to the building department and then you may schedule a final inspection which is the last step to the close out. Should you have any questions or require any further assistance please feel free to contact me at the office. Thank you for choosing Franzoso Contracting! Sincerely, A� I -- Ashley Schupbach Administrative Assistant ?,' ..SA'r.•�" '' ,Ar ,k?+?"''' �'w . ...nt,`K'''�,, ,1�w'r ^^Slh �--, ,--,. l+tr•' -!AA�_ i Mfrlr so vhykf°� a \'{'}t 1O '' :irr�� ;r•• \O r 4r1, vo 4}Fr, �,.0 t7 .•1, :\ Lr- �; �,y '';i y4 I 5' •n. ,'� L'i1 .� :,'•17�1 `1ti� �. ���'�rr p., .,,. p tidy :4?d!„A lt�f(j� _� rl nti,5 r�FF u. v 'r�;�h tIl rMiji" � -';xYJ�R3:'A ;O�' 7'� r 1`r"tl 0. Y,fte' '- � I�I�It s tvt f , k ;1' ,, fgl/lfir._< ,Fe+➢ ,f11111/ff+�. 1 f',' 11111111l1� �? 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A ivy Y�it� v. +f'iiy,. ,t i¢ `�♦ a u. .�t. a,i Yr� f� .n '�?,f / 'tiC;•p��� A � ? n r: Mgr, vrnv�yvf'1 A 'f. i r titi Y� Y 'S1ti• -� •r7 q• t.,ti•y\ :�O .2/, 0(.,:-.JYSfj;lrlr`4:= ._,I.'•4��(„ '.. ilia \r'Nrryo r +.4Y•.'4'r4 r�0� �i } �oa s t �.�hN r�o� rtt�thh'• ,x0,'` eYS Rthh � {d '• �� �srr -?• fro x --. .,ram;. •tb+v "�.. .l,�I,� r:- b.'� YY�l�C`''% �}�`•'�'. �' < <�!l'F'��' Tn•�\y� f'?.%�d"n7":.:' •rJ Y�SY<` J�' �f �-'. DATE(MM/DDIYYYY) ACOR" CERTIFICATE OF LIABILITY INSURANCE 05/12/2021 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 Certificates NAME: ROBERT T.KIRKWOOD,INC. PHONE (914)769-9070 FAX (914)769-4706 A/C No Ext): A/C No 91 Washington Avenue E-MAIL SS: certificates@kirkwoodinsurance.com ADDRE INSURER(S)AFFORDING COVERAGE NAIL# Pleasantville NY 10570 INSURER A: Selective Insurance Company of the Southeast 39926 INSURED INSURER B: Merchants Mutual 23329 Franzoso Remodeling Corp.,DBA:Franzoso Contracting INSURER c: Selective Insurance Company ofAmerica 12572 33 Croton Point Ave. INSURER D: INSURER E Croton On Hudson NY 10520 INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDLSUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DD/YYYY MMIDD LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTE15 CLAIMS-MADE FX OCCUR PREMISES Ea occurrence $ 500,000 MED EXP(Any one person) $ 15,000 A S2332054 04/01/2021 04/01/2022 PERSONAL SADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY ®JEC LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: Employee Benefits $ 1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident ANYAUTO BODILY INJURY(Per person) $ A OWNED SCHEDULED S2332054 04/01/2021 04/01/2022 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident Uninsured motorist $ 1,000,000 UMBRELLA LIAR 4,000,000 OCCUR EACH OCCURRENCE $ B EXCESS UAB HCLAIMS-MADE CUP0000898 04/01/2021 04/01/2022 AGGREGATE $ 4,000,000 DED I X RETENTION$ 10,000 $ WORKERS COMPENSATION PER OTH YIN - AND EMPLOYERS'LIABILITY STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE 1,000,000 C OFFICERIMEMBER EXCLUDED? NIA WC9082556 04I01/2021 04/Ol/2022 E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Village of Rye Brook is included as an additional insured under general liability per blanket endorsement as respects work performed at 18 Berkley Drive, Rye Brook,NY 10573 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 PORK Workers' CERTIFICATE OF STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board la.Legal Name 8 Address of Insured(use street address only) 1 b.Business Telephone Number of Insured Work Location of Insured(Only required if coverage is specifically limited to (914)271-4572 certain locations in New York State,i.e.,a Wrap-Up Policy) 1 c.NYS Unemployment Insurance Employer Registration Number of Franzoso Remodeling Corp., DBA Franzoso Contracting Insured 3 Croton Point Avenue Croton on Hudson,NY 10520 1d.Federal Employer Identification Number of Insured or Social Security Number 471320112 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Selective Insurance Company of America Village of Rye Brook 3b.Policy Number of Entity Listed in Box"1 a" 938 King Street WC9082556 Rye Brook, NY 10573 3c.Policy effective period 04/01/2021 to 04/01/2022 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"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: Robert Kirkwood (Print name of authorized representative or licensed agent of insurance carrier) Approved by: A�,-,&0lll:/( 05/12/2021 (Signature) (Date) Title: Principal Telephone Number of authorized representative or licensed agent of insurance carrier: 914-769-9070 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