HomeMy WebLinkAboutBP21-229•. ��-
SECTION• •
TYPE OF •• i--
JOB LOCATION
OWNER---
CONTRACTOR
T. •
• + _ ,,
xro # FEE�%� s DATE•
INSPECTION RECORD
DATE
FOOTING
FOUNDATION
FRAMING
RGH FRAMING
INSULATION
PLUMBING C�
RGH PLUMBING
GAS 0
SPRINKLER
ELECTRIC 0
LOW -VOLT L�
ALARM Cl
AS BUILT O
FINAL
1NSP
OTHER APPROVALS
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VILLAGE OF RYE BROOK
MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR
Paul S. Rosenberg (914) 939-0668 Christopher J. Bradbury
MMM.ryebrook.org,
TRUSTEES BUILDING&FIRE
Susan R. Epstein INSPECTOR
Stephanie J. Fischer Michael J. Izzo
David M. Heiser
Jason A. Klein
CERTIFICATE OF COMPLIANCE
December 15, 2021
Bobalu Rye Brook LLC
4 Westview Avenue
Rye Brook, New York 10573
Re: 4 Westview Avenue, Rye Brook,New York 10573
Parcel I D#: 141.35-2-4
Building Permit#21-229 issued on 8/31/2021. for Three Replacement Windows
This certifies that the three new windows,installed under the above captioned permit has been
satisfactorily completed.
Sincerely,
Michael J. Izzo
Building&Fire Inspector
/tg
BuiLDINO DE-PARTME'NT For office use only:
E O V E PERMIT# 1-at-
nr� ♦"ILEA • OF RYE$A 0OK ISSUED: B-3(-tea
UEC ' 2021 8 IKING STREE4 YE BROOK,,NEN1' YORK 10573 DATE: --7't90D l
9 0646' FEE.: PAm qY�
VILLAGE OF RYE BROOK w' r 13. Jr
BUILD NG DEPARTMENT
ON OR 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
•rrrrrrrrrr►rrrrrrrrrrrririrrrrrrrrra##s#i+w.waaa#####waaaa##si•r#Vaw++#waa#aaa#a#isa•a###ia#iai+#a#i+a►a+###ir++++++#a#wr+#+
Address: LW
Occupancy/Use: Q:S Parcel ID is: S —�— _ Zone:
Owner: L'WCk�' C'MKJr'LC `^ Address: q wli,„t '_3 AV" Q-`k--'—&-GdL �1Y I OS13
P.E./R.A.or Contractor: � �- Address: a�l s Sat Cs e rt',r A}(w G
3,
Person in responsible charge: AID, Address: LOB
Application is hereby made and submitted to the Building Inspector of the Village of Rye Brook for the issuance of
Certificate of Occupancy/Certificate of Compliance for the structurel'construction/alteration herein mentioned in accordance
with law
STATE OF NEW YORK, COUNTY OF WESTCHESTER as:
UAC e�, _being duly sworn,deposes and says that he she resides at
I PV4 Name of Applicant) (No and Street)
in ' ?_War-a-C L ,in the County of in the State of 01 —that
(City Town Village)
he/she has supervised the work at the location indicated aboi e,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
for the construction or alteration of 3
Deponent further states that he/she has examined the approve 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 structureiwork 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 pan thereof herealier 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.
Swom to before me this (p Sworn to before me this
day of _ems- , 20 '-24 day of I Ctr..�r+T 20
L�� a
Signature operty Ow r Signat e of Applicant
L'tt ('y (--�t U__d \C �j
Print Name Property Owner Exwi Name of.Applicant
JOHN M SUOZZO
No unNOTARY PUBLIC, STATE OF NEW YORK No-arN Public
Registration No. 01 SU6070919 SHARI rvlEULt_O
Qualified in Westchester County Notary Public, State of NewYtrrl<
My Commission Expires March 11, 2022 No.01 -- '3
C} lali;ied in Wc:;,ch, ,ker County
Commission ExDires Januri,,i 29, 2+19--1
BR
o tim
1982. BUILDING DEPARTMENT
❑BUI DING INSPECTOR
SSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK
CODE ENFORCEMENT OFFICER 938 KING STREET • RYE BROOK,NY 10573
t` (914) 939-0668 FAx (914) 939-5801
www.ryebrook.org
- - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - -
(4 ADDRESS : Vim] V 1 � DATE: �- L f 1o)
PERMIT# a 1 L [� ISSUED: ICT: BLOCK; LOT:
LOCATION: _ `i'� 7 ` �" J OOCUPANCY
❑ VIOLATION NOTED THE WORK IS... [J 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
r
Home Improvement Agreement: Page 1
Home Depot License#'s - For the most current listin visit www.Homedepot.com/LicenseNum-bers
Aldervon Brown
Salesperson Name Registration # (Req. in CA,CT,ME,MD,MI,NJ,DC)
Home Depot U.S.A.,Inc.("Home Depot") or Authorized Service Provider named below will furnish, install and/or
service the equipment listed below at the price, terms and conditions as outlined on this form.
I. Service Provider Contact Information
The Home Depot I The Home Depot
Service Provider Contact Name Service Provider Company Name
(914) 347-6900 customercancellationnortheast@horn
Phone # SHMeFff6vider Email Address Service Provider License#(s)
2. Customer Information
Gaudreau Lucy Westchester 1-1WKM8BS6
Customer Last Name Customer First Name Store #/Branch Name Customer Lead/PO#
4 Westview Ave Port Chester NY 1 10573
Customer Address City State Zip
(914) 588-4 1 lucygaudreau@yahoo.com
Home Phone# Work Phone# Cell Phone# Customer Email Address
3. NOTICE OF RIGHT TO CANCEL
YOU MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR OBLIGATION BY CONTACTING
THE SERVICE PROVIDER OR STORE DIRECTLY; EMAILING SERVICE PROVIDER AT:
customercancellationnortheast@homedepot.com
OR DELIVERING WRITTEN NOTICE TO HOME DEPOT AT:
6 Skyline Drive I Hawthorne NY 10532
Address City State Zip
BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING, UNLESS THE STATE
SUPPLEMENT PROVIDES A DIFFERENT CANCELLATION PERIOD. THE STATE SUPPLEMENT
CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN YOUR STATE.
YOUR PAYMENT(S) WILL BE RETURNED WITHIN TEN (10) BUSINESS DAYS AFTER HOME
DEPOT'S RECEIPT OF YOUR NOTICE. YOU MUST MAKE AVAILABLE FOR PICKUP BY HOME
DEPOT OR SERVICE PROVIDER, AT YOUR SERVICE ADDRESS, AND IN SUBSTANTIALLY THE
SAME CONDITION AS WHEN DELIVERED, ANY MERCHANDISE OR MATERIALS DELIVERED
TO YOU. OR YOU MAY CONTACT HOME DEPOT FOR INSTRUCTIONS REGARDING RETURN
SHIPMENT AT HOME DEPOT'S EXPENSE.
THE LAW REQUIRES THAT THE HOME DEPOT GIVE YOU A NOTICE EXPLAINING YOUR RIGHT
TO CANCEL. PLEASE SIGN BELOW TO ACKNOWLEDGE THAT YOU HAVE BEEN GIVEN ORAL
AND WRITTEN NOTICE OF Y UR RIGHT T9 CANCEL.
Acknowledged by: a8J19/2021
us ome Signature Date
460 Standard Forru HI (21 Jul.21)(E) Generated Date nR1194?-n 21 Lead/PO# 1-1 W K AA R R S G
r
Home Services Exteriors Change Order
(Amend Scope of Work)
Home Depot License Ws
Home Depot license numbers are listed below,and at www.homedepot.com/licensenumbers
AL: 05972, 06238, 51289, 1924, 16036, EMP-5701; AK: CONE25084; AZ: R00092581, ROC252435; AR: 228160519, MP6616; CA: 602331;
CO: ME-30122, EC-7930, PC.0003126, MP.00190074; CT: HIC.533772, ELC.0203352-E1, HTG.0406972-D1, PLM.0288547-PI DE: HM-0000772,
PL-0002473; DC: 410517000372, DRM300281, PL-0002473; FL: EC0001440, EC13007199, CGC1514813, CGC1522717, CGC061641, CRC046858,
CAC1813767,CAC1818831,CFC1426021,CCC1331113,CCC1331130,CCC058300;GA:GCCO005540,RBC0005730,EN216765,GAREGCN208589;
GU: CLB-08-0124, R-0514-0062; HI: CT-22120; ID: 005190, RCE-19683, 022877, 024086, 024087, 022876; IL: 104017473; IN: PL11700034; IA:
C091302,24602, 24602;KS: 16-009627; KY: CE65260, ME65140,HM05813, M7838; LA: 883162,43690,43690, 557308,43960, 883162,LMP 6987,
LMNGF9285; ME: See link above; MD: 13793, 85434 42144, 76141, 404011589; MA: 9875, 112785, CS-107774; MI: 2102119069, 2101089942;
MN: BC147263, EA731567, M11732457, PC147263, PM-093715,PM-093716; MS: 22222-MC; MO: See link above; MT. 37730, ELE-EM-LIC-31718,
PLU-PM-LIC-13784; NE: 26085, 33118, NV: 38686, 84011, 84052, 82439, 82440. 82441, 82442; NH: 4324, GFE0802907, MBE1801069; NJ:
13VH09277500, 34EB0158400, 34EI0158400; NM: C86302; NY: See link above; NC: 31521, U.30834, 34277, 33747; ND: 29073, M-3759, 1634,
1636, 1638; OH: 46992, 46992; OK: 106339, 0135514, 80003095; OR: 95843; PA: PA142212; PR: SJ-14328-CN; RI: 9480, 8422; SC: GLGI10120,
CLG.110120, M104779;SD:EC3363,WaI-MD-RI104-16-1963-C,FLM-TX-RI108-16-1965C;TN: 47781,47781,47781,3899,3877;TX:TECL24447,
TICL113, TACLA1574C, TACLB14980C, M16451; REGULATED BY THE TEXAS DEPARTMENT OF LICENSING AND REGULATION, P, 0.
BOX 12157,AUSTIN, TEXAS 78711, 1-800-803-9202, 512-463-6599; WEBSITE: WWW.TDLR.TEXAS.GOV; RESPONSIBLE MASTER PLUMBER
RICHARD W. MOORE,JR., LICENSE M16451 STATE BOARD OF PLUMBING EXAMINERS, 919 EAST 41ST STREET P.O. BOX 4200 AUSTIN,
TEXAS 78745 1-800-845-6584; WT4195; DALLAS BU120698;VI: See link above; UT. 286936-5501, 286936-5501, VT. PM04663; VA: 2705068841;
WA: HOMED088RH, MOOREJR934LN, HOMEDDU825KQ, WASHICR849P6; WV: WV036104, WV036104, WV036104; WI: 1046796, 1375416,
DC-030700030;WY:C-40136
Customer Last Name Customer First Name Store# Lead or PO# Email
Customer Address City State Zip
THIS CHANGE,ORDER("Change Order")amends and changes(as described below)the Home Improvement Agreement between Customer and Home
Depot dated (the"Customer Agreement").Customer acknowledges that by signing below:(i)Customer authorizes the changes to the Scope
of Work listed on Exhibit"A" ,including any changes to plans and specifications;(ii)the Services will not continue until payment of additional charges
(if applicable)has been received by Home Depot;and(iii)all terms and conditions of the Customer Agreement remain in full force and effect and apply to
this Change Order.
Customer's Signature Service Provider Full Personal Name(Print)
Service Provider Full Business/Trade Name Service Provider Signature
Service Provider License Number(if applicable)
110 Horne Se-5 Evenors Change Order(M JU121t Generated Dale Lead;POP V 0.1.17
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Home Services Exteriors Change Order- EXHIBIT«A„
(Amend Scope of Work)
Nl indows and Patio Doors
Color °sez S Grids Hinges/Handings
& ls` w = S C
c $Increase/g n v w o r
Z do o Gas DecreaseSeries �
$ = Options
G Uj c Z
a
<
r sc;
bt• wti: 3 >-� AA-
flo—
il 32 2A VA
Miscellaneous L 0
Reason for Change r 11"Ie— S,-,
DESCRIPTION OF CHANGE REASON FOR CHANGE S Increase/
Decrease
Orginal Contract AmourA6
Change to Scope of Work Amount: ,
Change to Promo(if applicable): ., ,,-
Sales Tax(if applicable): A14
Customer Initial New Contract Amount:;, /,
110 Home Serves Exton—Charge O,de,(06 JUl 21) Gweraled Dal. Lead/P0# v 0 1 17
Building Permit Check List&Zoning Analysis
Address: Lk 31 �:—V �l t F W k-4- SBL: `'� I 3 Sr, -Z -41
Zone: •j_ Use: Const.Type: Other.
Submittal Date: `' ��(0 f Z k Revisions Submittal Dates:
Applicant: Au 2FA v
Nature of Work �— 'tom s�[�AC�u -t�✓• W t,/v ,�� Al L
Reviews:ZBA AUG 2 6 2021 PB- BOT: Other.
OK
( ( ) FEES:Filing. 7S'- BP: o� C/O: Legalization:
( ) (,�'APP: Dated ✓ Notarized: ✓ SBL -truss I.D. Cross Connection: H.O.A.:
( ) ( ) Scenic Roads: Steep Slopes: Wetlands: Storm Water Review: Street Opening.
( ) ( ) ENVIRO: Long. 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.
( ) ( ) CODE 753#: Dated N/A:
( ) ( ) H1GH-VOLTAGE ELECTRICAL:Plans: Permit N/A: Other.
( ) ( ) LOW-VOLTAGE ELECTRICAL:Plans: Permit: N/A: Other.
( ) ( ) FIRE ALARM/SMOKE DETECTORS:Plans: Permit: H.W.I.C.:_Battery._Other.
( ) ( ) PLUMBING:Plans: Permit Nat.Gas: LP Gas: N/A/: Other:
( ) ( ) FIRE SUPPRESSION:Plans: Permit N/A: Other.
( ) ( ) H.V.A.C.: Plans: Permit N/A Other.
( ) ( ) FUEL TANK:Plans: Permir. 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: APPROVED
Aa. TI REQUIRED EXISNG PROP osED N �' A U G 2 6 2021,
Date:
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AC O� DATE(MMIDDIYYYY)
CERTIFICATE OF LIABILITY INSURANCE 0212612021
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
NAME:
MARSH USA,INC. PHONE IA/C.AX
TWO ALLIANCE CENTER (AIC,No ExtNo:
3560 LENOX ROAD,SUITE 2400 E-MAIL
ATLANTA,GA 30326 ADDRESS:
INSURER(S)AFFORDING COVERAGE NAICi
CN101642069-HomeD-GAW.-21-22 INSURER A: Old Republic Insurance C 24147
INSURED INSURER B: AIU Insurance Co 19399
THE HOME DEPOT,INC.
HOME DEPOT U.S.A.,INC. INSURER C: HomeRisk Captive Insurance Company NIA
2455 PACES FERRY ROAD INSURER D:
BUILDING C-20
ATLANTA,GA 30339 INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: ATL004348037-14 REVISION NUMBER: i
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 SUBRPOLICY
POLICY NUMBER M DD EFF POLICY E
XP
LTR YYY M DD YY �LTs
A X COMMERCIAL GENERAL LIABILITY MWZY 314574 031010019 0310112022 EACH OCCURRENCE $ 1,000,000
RENTED
CLAIMS-MADE F OCCUR PREMISES A AGE TOEa occur'..)
ccurrence $
1,000.000
X SIR:$1,000.000 MED EXP(Any one person) $ EXCLUDED
PERSONAL&ADV INJURY S 1,000,OD0
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
X POLICY❑ PRO• ❑ PRODUCTS-COMP/OP AGG $ 2,000.000
JECT LOC
OTHER: $
A AUTOMOBILE LIABILITY MWTB314573 03/0112019 0310112022 MBINED SIN LE LIMIT $ 1,000,000
Ea accident
X ANY AUTO SELF INSURED AUTO PHY DMG BODILY INJURY(Per person) $
OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY AUTOS ONLY Per accident
$
UMBRELLA LIAR OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE S
DED 1 1 RETENTIONS $
B WORKERS COMPENSATION WC 58240269(WI) 0310112021 03101J2022 X STATUTE ER
H
AND EMPLOYERS'LIABILITY
B ANYPROPRIETORIPARTNERIEXECUTIVE YIN NIA WLR C678182581NC,VA} 03I0112021 0310112fl22 E.L.EACH ACCIDENT $ 5.000.000
OFF an,dat ry in N R EXCLUDED? ❑N Continued on Additional Page E.L.DISEASE-EA EMPLOYEE $ 5,000,000
(Mandatory in NH) 9
II yes.describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE•POLICY LIMIT $ 5.000,000
C Excess Auto 297110011002021 03101I2021 03101/2022 Limit: 4,000,000
A Excess General Liability MWZX 314580 0310112019 03101/2022 Limit: 8,000,D00
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
VILLAGE OF RYE BROOK IS INCLUDED AS ADDITIONAL INSURED IF REQUIRED BY WRITTEN CONTRACT ON THE ABOVE GENERAL LIABILITY POLICY,BUT ONLY WITH RESPECT TO
LIABILITY ARISING OUT OF THE OPERATIONS OF THE NAMED INSURED.
CERTIFICATE HOLDER CANCELLATION
VILLAGE OF RYE BROOK SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
938 KING STREET THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
RYE BROOK,NY 10573 ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
of Marsh USA Inc.
Manashi MukherjeeA °a'"
c 1988-2016 ACORD CORPORATION. All rights reserved.
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD
YOK Workers' CERTIFICATE OF
STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE
gOarCl
1a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured
Home Depot USA,Inc. 770-433-8211
2455 Paces Ferry Road,C-20
Atlanta,GA 30339 1 c. NYS Unemployment Insurance Employer Registration Number of
Insured
76011130
Work Location of Insured(Only required if coverage is specifically limited to 1d. Federal Employer Identification Number of Insured or Social Security
certain locations in New York State,i.e.,a Wrap-Up Policy) Number
58-1853319
2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier
(Entity Being Listed as the Certificate Holder)
AIU Insurance Company
Village of Ryebrook 3b. Policy Number of Entity Listed in Box"1 a"
Building Dept.
938 King Street 058240268
Ryebrook,NY 10573
3c.Policy effective period
03101/2021 to 03/01/2022
3d.The Proprietor, Partners or Executive Officers are
[ included.(Only check box if all partners/officers included)
all excluded or certain partners/officers excluded.
This certifies that the insurance carrier indicated above in box"3"insures the business referenced above in box 1a"for workers'
compensation under the New York State Workers'Compensation Law.(To use this form,New York(NY) must be listed under Item 3A
on the INFORMATION PAGE of the workers'compensation insurance policy). The Insurance Carrier or its licensed agent will send
this Certificate of Insurance to the entity listed above as the certificate holder in box"2".
The insurance carrier must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy is canceled
due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or
eliminate the insured from the coverage indicated on this Certificate.(These notices may be sent by regular mail.) Otherwise,this
Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent, or until the policy
expiration date listed in box"3c",whichever is earlier.
This certificate is issued as a matter of information only and confers no rights upon the certificate holder. This certificate does not amend,
extend or alter the coverage afforded by the policy listed, nor does it confer any rights or responsibilities beyond those contained in the
referenced policy.
This certificate may be used as evidence of a 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: Michael Price
(Print name of authorized representative or licensed agent of insurance carrier)
f,�
Approved by: r f `" 02/27/2021
(Signature) (Date)
Title: C.E.O. North America
Telephone Number of authorized representative or licensed agent of insurance carrier: 212-770-7000
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