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HomeMy WebLinkAboutBP21-218PERMIT # C� r DATE: p(P; o7CM)cz)I, SECTION �3, 57.4l% BLOCK LOT �^Sy ��• ! J TYPE OF WORK IJUr 108 LOCATION 077 /nP CON7F2Pik / /J2f' c 4C717n �Or 7. COEPEE EE_ po v FEE DATE INSPECTION RECORia DINE FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING RGH PLUMBING GAS ED SPRINKLER ELECTRIC LOW -VOLT O ALARM 0 AS BUILT FINAL INSP 7P713-5c)34 i2rgA0 4raajo (9/y)00# aka a�-I la 3pyrl�ctj l�lu��Vo R APPROVALS ARB BOT PB ZBA OTHER VILLAGE` RYE BROOK WESTCHES' � COUNTY, NEW YORK ��; a� \t�.• 21-196 Certificate of ®rrupaurp This is to certify that ! t- of, R)le, l)Vdd AJ having duly filed an application on Denem bf r 7, 20 requesting a Certificate of Occupancy for the premises known as, P/i l(!f 9 I d Road , Rye Brook,NY, located in a Zoning District and shown on the most current Tax Map as Section: . >� Block: Lot: , and having fully complied with the requirements of the Building Code and the Zoning Ordinance under Building Penn it No.C9! " /5 , issued SJc:D-O 20 � , 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 New York State Use Classification of: �— If— F ,for the following purposes: lr1-�er J c �e� cr)(0 ya c�,� Subject to all the privileges, requirements, limitations and conditions prescribed by law, and subject also to the following: This certificate does not in any way relieve the owners or any person or persons in possession or control of the premises, building,or any part thereof from obtaining such other permits or licenses as may be prescribed by law for the uses or purposes for which the building or premises is designed or intended. Furthermore, it does not relieve such owners or persons from complying with any lawful order issued with the object of maintaining the premises or building in a safe and lawful condition. No changes or rearrangement in the structural parts of the building or in the exit facilities shall be made,and no enlargement, whether by extending on any side or by increasing in height shall b made,nor shall the building be moved from one location to another until a permit to accomplish such change has been bt in om Z713W ' g Inspector. Building Inspector,Village of Rye Brook.: Date: DEC — 9 2021 ED E C E N � For office use onl BUILDIr`fEAtTMENT PERMIT# �$ DEC - ] 2021 VILLAGE OF RYE BROOK ISSUED: � $KING STREET,RYE BROOK,NEw YORK 10573 DATE: — I VILLAGE OF RYE BROOK (914)939-'066$ FEE: FAm BUILDING DEPARTMENT www,rvebroojLorj! 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 #►►#►!#►i►i►►#►►►►4##►►►►i►►►###►if####►i,(i#####F►t####R►#R##►#►►#*########►######►►►!###i#►►#►►tikid#►i####t►ii►►►i##t►►#►►• Address: Occupancy/Use: I -Fo ) Parcel ID#: I�� `T I- `� Zone: Owner: / ����,r.A 1) Address: P.E./R.A.pf Contractor: Address: Person in responsible charge: Address: Application is hereby made and submitted to the Building Inspector of the Village of Rye Brook for the issuance 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:_ LlkV � V 0 V 'FWF— being duly sworn,deposes and says that he/she resides at (Print Name of Applicant) (No.and Street) in R4F _ ,in the County of 11111 C - j 1 G/� _in the State of that (City/Town/Village) he/�as 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:$ 2-1); d D Q , for the construction or alteration of 1 < f - N (tj IN (' Deponent further states that h site has examined the approved plans of the structure/work herein referred to for which a Certificate of Occupancy/Compliance is soug ,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 mee this Sworn to before me this � day of `,,{bhi t — , 20 2 ( day of , 20 Signature of Pro perty perry Owner Signature of Applicant ' / Print Name of Property Owner ` Print Name of Applicant o 3�_ Public Notary Public PATRICIA A. SCHOFIELD NOTARY PUBLIC-STATE OF NEW YORK 8/12/2021 No.01SC5086075 Qualified In Westchester County My Commission Expires 10-06-202j BRC>O� 04 Z� w � BUILDING DEPARTMENT ❑BUILDING INSPECTOR SSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK 116 CODE ENFORCEMENT OFFICER 938 KING STREET • RYE BROOK,NY 10573 (914) 939-0668 FAX (914) 939-5801 www.ryebrook.org - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - -- - - - - - - - - - - - - ADDRESS : j� 'k DATE: LR� L-cr f PERMIT# � _� 1 ISSUED: !SECT: BLOCK: LOT: LOCATION: Q s sz,C I L S j r1 E 1h^� OCCUPANCY: —7 ❑ VIOLATION NOTED T RE 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 in • 7 N fV Lw ..r .••, O a o r � 0 O ' F tn G W S ` Oy Qom„ � U cs • Grp O r- en > c j t W © •.• C4 ti O Q N � (A F C Q tu V o, o y o a0 _ v6 F+i W o v A .. O00W W GA W V owl COO z00 06. W. Z a �' > m • r O Q Ck W C C!� ® W W a 3 oa � z4 Z •' .5 a. W m' i 449 fig 94444441ttoVito 44164AU4A4A444U4 46444444;441G4 Q4A4& BUILDING DEPARTMENT D VILLAGE OF RYE BROOK LO T 13 2021 938 KING STREET RYE BRoox,NY 10573 (914)93910668 VILLAGE OF RYE BROOK wvvv .r�ebrook.or'" l BUILDING DEPARTMENT ELECTRICAL PERMIT APPLICATION Westclleste'r Cbtlnly Muster Eiectricialns Lice s'e Reptred �10Ql- =zs 7 Approval Date: OCT A, Permit Fee: $ 450 —Approval'Signature: Other: Oisapproved (fern are non-reAmdable) Application dated, 0 "l is hereby made to the Building Inspector of the Village of Rye Brook NY, for the issuance of a Permit to install and/or remove electrical equipment,wiring, fixtures,or to perform other high or low voltage electrical work as per the detailed statement described below. The applicant & property owner, by signing this document agree that all electrical work performed will be in conformance with all applicable Federal, State,County and Local Codes. 1.Address: -7 TI A)It !nc 1 SBL:_ 1 35-t{l � ^ S� Zone: 2.Property Owner: L)o<(VAiei2 t L,U4M BANDIek-Address: - - Phone#: 1` -?��-s L3 G' Cell#: email: 3.Master Electrician: f iewo s gTwo Address: -4 qrW e*0eZ _5 7-G_ f eeAXO( 41 L-r iq& '3/ Lic.#: `r l Phone#: J1y'aa17-FS�13 Cell#: email: 5usT-/244b eA.� j-C yAA00•-00 i1j Company Name: FS &InC ele C.cc Address: YVWeAVP-k ST- 611i`)�ektveCG C7-0&9 4.Proposed Electrical Work/Fixture Count: F.e+' 0'T((7a► 07 - PiTueu To XAJ('Ade Cs "e ) UlS 6A25Aet— ,&ear t Aa-T-04, 6,ar b"E' 0 1 se�- 4 6e FCL 6Q 7-1 e I-S G JC.147 AzI Oc.G. Is ccS S LuLn J-(vrt;6-i AA*AAAAAAAAAAAAAAAAA#AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA#AAAAA#AAAAAAAAA#A#AA##iAAA###AA###!#A########R#####AA STATE OF NEW YORK,COUNTY OF WESTCBESTER ) as: j e4-0 s A-T./vu ,being duly swom,deposes and states that he/she is the applicant above mined,and does further sprint n.inw ul individuA siLIrune u.v the applioont" state that(s)he is the legal owner of the property to which this application pertains,or that(s)he is the for the legal owner and is duly authorized to make and file this application. (m dwafe nrcltitcut,%ttmirao or,gena,uuome .eta i The undersigned further states that all statements contained herein are true to the best of his/her knowledge and belie&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 ) 5'" Sworn to before me this 13 TH day of ©CTodUQ 20 t 7daM�a*3 202-/ Signature of Property Owner Sighature of App tcant F1 eT,<, .St7-A n1U Print Name of Property Owner Print Name of Applicant Notary Public Notary Public DONALD A CASSONE Notary Pubic, State of New York No 01 CA6061097 Qualified in Westchester County Commission Expires July 9 20Z3 8112/2021 f J Westchester Rockland Electrical Inspection Services, Inc. Phone: 914-347-3595 DO NOT WRITE HERE--FOR OFFICE USE ONLY 43 North Lawn Avenue y Fax: 914-347-3596 Elmsford, NY 10523 BUILDING PERMIT NO, TEMP# DATE �f 1 CITY OR VILLAGE ZIP CODE TOWNSHIP COUNTY . ,TOOK- T -s?�.r STREET AND NO.OR ROAD POLE NUMBER BETWEEN WHAT TWO CROSS STREETS IS PREMISES LOCATED? SECTION BLOCK LOT OCCUPANT'S NAME /1 BUILDING OCCUPANCY OWNER'S NAME AND ADDRESS HOME TELEPHONE NUMBER kF I CURRENT SUPPLIED BY FROM THEIR OFFICE WORK TELEPHONE NUMBER LIST BELOW ALL EQUIPMENT WHICH YOU INSTALLED NUMBER OF OUTLETS NO.OF FIXTURES& MOTORS HEATERS OFFICE USE LOCATION LAMP RECEPTACLES ONLY SIDEWALL SWITCH INCADE FLUORE NO. H.P.EACH NO. WATTS EACH INSPECTION OUTSIDE rf ` E L ] BASEMENT I I' FL 2 FL, 3"'FL. VILLA SE OF RYE BR OK REMARKS:LIST OTHER ELECTRICAL DEVICES NOT SET FORTH ABOVE: ,K l rT,✓.� T r^, JI:•.I,: r 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 1 ADDITIONAL I7 EXPOSED F 1 CONCEALED a MUST ENTER APPLICANTS IDENTIFICATION NUMBER SERVICE ENTERS BUILDING OVERHEAD[] UNDERGROUND L] AVOID DELAYS BY GIVING FULL AND ACCURATE INFORMATION.ALL SPACE MUST BE FILLED IN OR APPLICATION MAY BE RETURNED. NAIVE PANY DATE OF APPLICATION SIGNATURE OF APPLICANT r /� STREET ADDRESS TELEPHONE NO. C1!Y OR ZIP CODE LICENSE NO,WHEN APPLICABLE /� Aft WESTCHESTER ROCKLAND ELECTRICAL INSPECTION WRE15SERVICES,INC. BY THIS CERTIFICATE OF COMPLIANCE THE Westchester Rockland Electrical Inspection Services 43 North Lawn Ave, Elmsford, NY 10523 914-347-3595 (Office) 1914-347-3596 (Fax) CERTIFIES THAT Upon the application of: Upon premises owned by: PS Electric Inc. Ray Vollmer& Laura Bandler-Vollmer 245 Weaver Street Apt 5G CT, Greenwich 06831 Located at:7 Pine Ridge Rd Rye Brook, NY 10573 Certificate Number: 1032009 Section:135.41 Block: 1 Lot: 54 BDC: Permit Number: EP:21-257-BP:21-218 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: 7 Pine Ridge Rd Rye Brook,NY 10573 Basement ®1st 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 12/02121 Name Type Quantity Cook Top ------- 1 Microwave ------- 1 Dishwasher ------- 1 Refrigerator ------- 1 Receptacle GFCI ------- 4 Fixture-Luminaire Recessed ------- 11 Fixtures Pendant ------- 3 Switch Single Pole ------- 4 This Certificate has been approved by Westchester Rockland Electrical Inspection Services. This certificate may not be altered in any way. This certificate is valid for work performed before date of inspection only. i I r fh r � a N 00 W yU a ` m u C � �O A v O M M �, o C m x Z _. F. II � C, 00 • w A � o w W aU r V r M ' � Z Y, W p1 F-I Qa �p v 0 CO ,,..� 4 40en w t 04 � w x � w N E o un ►-a A u �' Ca c Qn = O O Z p ..a w M G aW. G p EC'I�L"�? BUILDING DEPARTMENT OCT " 6 2021 VILLAGE OF RYE BROOK 938 KING STREET RYE BROOK,NY 10573 VILLAGE OF R OK YE BRO (914)939-0668 BUILDING DEPARTMENT wcvW ook.org PLUMBING PERMIT APPLICATION FOR OFFICE USE ONLY BP#: c:;)��d 1 PP#: 1_&3 Approval Date: OCT 8 011 Permit Fee: $ 300-16b) Approval Signature: Other: Disapproved: (fees are non-refundable) Application dated,/0��of is hereby made to the Building Inspector of the Village of Rye Brook NY,for the issuance of a Permit to install and/or remove Plumbing as per detailed statement described below.The applicant&property owner,by signing this document agree that said plumbing work will be in conformance with all applicable Federal,State,County and Local Codes. 1.Address: '? Pi N g- "6- AK SBL: Zone: —�OZ 2.Proposed Work: A C rt T r- b t ice[ 51^J K 3.Property Owner: Address: Phone#: Cell#: email: 4.Master Plumber: .I�s Wif . ]N yaPal Address: a s Lic.#: Phone#: q10-:224 f30 Cell#: FA'76 7!ro 0 email: 3 [, Company Name: IX 4,2, d n'1-y IN 13 Address; 5 reW INDICATE FIXTURES&LINES TO BE INSTALLED AS PER THE FOLLOWING SCHEDULE: Location 'Water Urinals Drinking Sinks Showers Bath Laundry Domestic Fire Sanitary Natural/ Other* Total Closets Fountains Tubs Tubs Service Service Sewer LP Gas Basement 1st Floor i 2nd Floor 3'Floor 4's Floor 51 Floor Exterior 5.*List Other Equipment/Provide Details: (Notarized Signatures Required Next 2 Pages) 4- si12/2o21 S TE OF NEW YORK,COUNTY OF WESTCHESTER ) as: being duly sworn,deposes and states tha h9she is the applicant above named, (print e 6f individual signing as the applicant) and cr states that( he iiss the legal owner of the property to which this application pertains,or that(sGs 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. Sworn to before me this 1d1 Sworn to before me this day of ,20 Z r day of ,20� r � ature o fOr operty Owner )' of Applicant 7cla t�Llr Print Nahe of Property Owner Print Name of Applicant IF EL'k 00 1_UL—_ No to of New York "WATRICIA A. SCHOFIELD No. o1Pt:160063 NOTARY PUBLIC-STATE OF NEW YORK Oualified in Westchester County —7 NO.O t SC5086076 Cornmission Expires January 29,20�j Qualified In Westchester County This appiltTIBM4> NJ%b MApleted in its entirety and must include the notarized signature(s)of the legal owner(s)of the subject property, and the applicant of record in the spaces provided. Applications not properly completed in its entirety and/or not properly signed shall be deemed null and void and will be retumed to the applicant. _2_ 8/12/2021 BUILDING:DkPARTMENT VILT AGE OF RYA kOOK OCT - 6 2021 938 K NG$'SET RYF,BROOk,NY 10573 r . VILLAGE OF RYE BROOK BUILDING DEPARTMENT AFFIDAVIT OF COMPLIANCE VILLAGE CODE $216 - STORM SEWERS AND SANITARY SEWERS THIS AFFIDAVIT MUST BEAR THE NOTARIZED SIGNATURE OF THE LEGAL PROPERTY OWNER AND BE SUBMITTED ALONG WITH ANY BUILDING OR PLUMBING PERMIT APPLICATION. ANY BUILDING OR PLUMBING PERMIT APPLICATION SUBMITTED WITHOUT THIS COMPLETED AND NOTARIZED FORM WILL BE RETURNED TO THE APPLICANT STATE OF NEW YORK, COUNTY OF WESTCHESTER ) as: ,O ' ,residing at, /�/C`' , (Print name) (Address ere you live) be 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; ;7z > ,Rye Brook,NY. (Job Address) Further that all statements contained herein are true, and that to the best of his/her knowledge and belief,that there are no known illegal cross-connections concerning either the storm sewer or sanitary sewer,and further that there are no roof drains, sump pumps, or other prohibited stormwater or groundwater connections or sources of inflow or infiltration of any kind into the sanitary sewer from the subject property in accordance with all State, County and Village Codes. (signof Property Owner(s)) (Print a of Propeity Owner(s)) Sworn to before me this day of VIA110%V, , 20 2, Lary Public) PATRICIA A. SCHOFIELD NOTARY PUBLIC-STATE OF NEW YORK No.01SC5086075 Quatified In Westchester County _3 My Commission Expires 10-00.2021 8/12/2021 Building Permit Check List&Zoning Analysis Address: SBL: ! 3- _ ' Zone:_Tj-1 Z Use: Z s Const.Type: -2Pk Other. Submittal Date: (D Z Revisions Submittal Dates: Applicant: V O L.I wi 4:-- n— Nature of Work r— Reviews:ZBA AUG 1 7 7071 PB.. BOT: Other. OK ( ( ) ES:Filing. BP: QO- --C/O: Legalization: ( ) (. P: Dated: ✓ Notarized: ✓ SBL: --I`russ I.D. Cross Connection: /H.O.A,: ( ) ( ) Scenic Roads: Steep Slopes: Wetlands: Storm Water Review: Street Opening ( ) ( ) ENVIRO: Long. Short: Fees: N/A: ( ) ( ) SITE PLAN:Topo: Site Protection: S/W Mgmt.: Tree Plan: Other.- SURVEY:Dated: Current Archival: Sealed: Unacceptable: ( ) ( ) PLANS:Date Stamped Sealed: Copies: Electronic Other. ( ) (. License: ✓ Workers Comp: ✓ Liability: ✓ Comp.Waiver. Other: O O CODE 7S3#: Dated N/A: HIGH-VOLTAGE ELECTRICAL:Plans: Permit: N/A Other. ( ) ( ) LOW-VOLTAGE ELECTRICAL:Plans: Permit: N/A: Other. ( ) ( ) FIRE ALARM/SMOKE DETECTORS:Plans: Permit: H.W.I.C.:_Battery:_Other: (� ( ) PLUMBINCx Plans: Permit Nat. Gas: LP Gas: N/A/: Other. ( ) ( ) FIRE SUPPRESSION:Plans: Permit: N/A: Other. ( ) ( ) H.V.A.C.: Plans: Permit: N/A Other. ( ) ( ) FUEL TANK:Plans: Permit Fuel Type: Other. ( ) ( ) 2020 NY State ECCC: N/A: Other. ( ) ( ) Final Survey Final Topo: RA/PE Sign-off Letter: As-Built Plans: Other. ( ) ( ) BP DENIAL LETTER: C/O DENIAL LETTER: Other. ( ) ( ) Other: ( )ARB mtg. date: approval notes: ( )ZBA mtg.date: approval notes: ( )PB mtg.date: approvaL notes: REQUIRED EXISITNG PROPOSED NOTFS P�OVED � �: 9 2021 Circle: Froaw Front Front 5do: Main Coy Accs.Cov FL H/Sb: Sd.H Sb: SSA: Tot.imp: Ft Imv: Hd& Stories: notes:� 9 F l J 4OZ-- (J :wml� zx be CL cr 0 0 Cl) L"-j 0 Lij 7 ction U) z LLI < 'Ll I — �. 11 c: 7 .2 ; LLJ 7 .1 r LLJ Ile- z O LU 6w U) SLA C C05 4f 2 C4 40 Raioil ,4CQRi©e CERTIFICATE OF LIABILITY INSURANCE DATEIM2,WiM `II CERTIFICATE �a Xr2 i 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(les)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 CUNIALT NAME. hen 1 lhrnl PNONE, FAX 1+Ycc Imur-amc AIC No E,tt• N95992?211q (AK,Nei. )oK'cc Pius ADDRESS- scrl'ICc'df0,,cel its.corn INSURER($)AFFORDING COVERAGE NAIL a c,"r.Isolr. \l 111Y90 INSURERAr IrVANSTONINSCO c'"x rsJRED q INSURER B: sERGIO GE\FR 1L t'tI\TR Nt 1 I\U i'oRP INSURER[ _ \ORI AS RD INSURER D: INSURERS: C R?F\L1Try CT Of,xtll_f,u l h INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: c:C JER-71 ThA'-'-IE PJLtLiES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD ICATED NCTYvITHSTANDING ANY REOUIREMENT TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS e'"c'CATE MAY BE'.SS�ED OR AWAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, E+--_S"Z%S AND C2\—_TIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID LLAIMS. .'R 'YPE OF INSURANCE 'ala0 yyVD POLICY NUMBER MMIO LIMITS COMMERCIAL GENERAL UAWTY X EACH OCCURRENCE S 2.IN10,fNNl _4nAS�ks,^.E OCCUR PREMISES(Fa ocrunencal S III(1 fNNI NED EXP(Any—eelwnl S S.fNNI Y �AA95055 OY22/2021 (1322-1022 PERSONAL A ADV INJJRY 3 ".ullo,ow GENERAL AGGREGATE 3 9.0()(I,NX) PRODUCTS-COMPIOP AGG S 9.0tH)000 - is A'.^.OIrOB[LE.(ABL.RY (Ea acudenri S BODILY INJURY(Pe penavr I S 7e'%F___N_ AVf05OS '`ED AUTOS BODILY INJURY Re--d—tl S NO%4)Mf,aEO S AJT DN OS ,Y erscods-'. _ S JMISREL_A LIRE OCCUR EACH OCCURRENCE S 1 EXCESS LIAR CLAIMS4ADE AGGREGATE S :i" PF-F4TIONS S WORKERS COMPENSATION - AMC EMPLOrERf LMUTY YIN STATUTE Ecl En Y PROPRir"DR.PARTNE.R'EXECUT NE 1—f NIA E-L.EACH ACCIDENT 3 F,CERWEUSER FXCLUOEIr w4sla ry II NNI E L DISEASE-EA EMPLOYEE S das under QtM _aro"r_,,„CF OPERATIONS belax El DISEASE•POLICY LIMIT 3 DESCRIPTION OF OPERATIONS i LOCATIONS I VENKUS ACORD 101.Addelonal Remarks Schedule,may be attached a more space Is required) {cmtica.!c louder named a-additional in.urcd. 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 Hr«,I: ACCORDANCE WITH THE POLICY PROVISIONS. 93H King St AUTHORIZED REPRESENTATIVE sat" by Jaya Itve Biook NY I05"1 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 2S(2016103) The ACORD name and logo are registered marks of ACORD NYSIF Neu York State Infurance Fund WESTCHESTER ONE,44 SOUTH BROADWAY,10TH FLOOR,WHITE PLAINS,NY 106014411 1 nysif.com CERTIFICATE OF WORKERS'COMPENSATION INSURANCE (RENEWED) "..... 522454246 r+ JOYCEINSURANCE a 2 JOYCE PLAZA ■❑ STONY POINT NY 10980 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER SERGIO GENERAL CONTRACTING CORP. VILLAGE OF RYE BROOK 22 NORM ROAD 938 KING STREET GREENWICH CT 06630 RYE BROOK NY 10573 POLfCY NUMBER CERTIFICATE NUMBERT POLICY PERIOD DATE W2275 662-1 732145 G4 12 01202 1 TO 04/20/2022 7/27/2021 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2275 662-1, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUTSIDE OC NEW YORK, TO THE POUCYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY, IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTPS:IIINWW.NYSIF.COM/CERTICERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THIS POLICY DOES NOT COVER CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED BY THE OFFICERS OF THE INSURED CORPORATION. PRESIDENT SERGIO ARAUJO SERGIO GENERAL CONTRACTING CORP. 1 OF 1 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. BY CAUSING THIS CERTIFICATE TO BE ISSUED TO THE CERTIFICATE HOLDER, THE POLICYHOLDER UNDERTAKES TO PROVIDE THE CERTIFICATE HOLDER 5 CALENDAR DAYS' NOTICE OF ANY CANCELLATION OF THE POLICY. NEW YORK STATE INSURANCE FUND DIRECTORINSURANCE FUND UNDERWRITING VALIDATION NUMBER 1059180272 U-26.3