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HomeMy WebLinkAboutBP21-235PERMIT #",/ SECTION IQ TYPE OF WORI JOB LOCATION OWNERt CONTRACTOR_ EST. vCO # Dl- c )35 DATE- /u I)/ EXP., jo % BLOCK LOT, &I P� m ell l.I TCO # FEE DATE INSPECTION RECORQ DATE FOOTING FOUNDATION FRAMING RGH FRAMINGz INSULATION _ PLUMBING _ RGH PLUMBING - GAS Q SPRINKLER �j a ELECTRIC [�( LOW"VOLT 0 - ALARM 0 AS BUILT FINAL I NSP as ./'P_ k)/�Jo)OI4) y03- 51775 Ay 6)1 1.)ql AleL OTHER APPROVALS ARB BOT PB ZBA OTHER FINISHED BASEMENT NOT APPROVED FOR USE AS A SEPARATE APARTMENT OR DWELLING UNIT VILLAGE OF RYE BROOD WESTCHESTERCOUNTY, NEW YORK No: 22-015 Certificate of Occupaucp Eli is is to certify that � � 1"8-UC&)'a1-7 of, )Y., �YQ K , / V y having duly Bled an application on /V oyPily7 ber 2?��20 a I requesting a Certificate of Occupancy for the premises known as, ' IC) 8 e I le F f r AbO t , Rye Brook,NY, located in a PU 0 Zoning District and shown on the most current Tax Map as Section: 4 , !3 Block: f Lot: �P VV and having fully complied with the requirements of the Building Code and the Zoning Ordinance under Building Permit No. p( I"v�� , issued [/0 20 -2 /, such authority and permission is hereby granted to the property owner to lawfully occupy or use said premises or building or part thereof listed under the New York State Use Classification of: `�.J - Y to// ,for the following purposes: r'.ea room , bn+h moyn r)ew earnrs 4o1ndp&, Subject to all the privileges, requirements, limitations and conditions prescribed by law, and subject also to the following: FINISHED BASEMENT NOT APPROVED FOR USE AS A SEPARATE APARTMENT OR DWELLING UNIT 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 be made,nor shall the building be moved from one location to another until a permit to accomplish such change has b e o 'lding Inspector. Building Inspector,Village of Rye Brook: ate: ,BAH 2 7 2022 VILLAGE OF RYE BROOK MAYOR 938 King Street,Rye Brook,N.Y. 10573 ADMINISTRATOR Paul S.Rosenberg (914) 939-0668 Christopher). Bradbury www.ryebrook.org TRUSTEES BUILDING&FIRE Susan R. Epstein INSPECTOR Stephanie J. Fischer Michael J.. Izzo David M. Heiser Jason A. Klein CERTIFICATE OF COMPLIANCE January 27, 2022 Dena Bruckman 40 BelleFair Road Rye Brook,New York 10573 Re: 40 BelleFair Road, Rye Brook, New York 10573 Parcel l D#: 124.73-1-66 Mechanical Permit#21-129 issued on 9/10/2021 to Legalize Fire Sprinkler Heads This certifies that the fire sprinkler heads,installed under the above captioned permit, has been satisfactorily completed. Sincerely, Michael J. Izzo Building&Fire Inspector /tg DEC For office use onl ID BUILDING T E "IMENT PERMIT# c� _ E, NOV 2 ZO2I VILLAGE OF RYE BROOK ISSUED: -/O 938 KING STREETS RYE BROOK,NEw YORK 10573 DATE: VILLAGE OF RYE 'BROOK (914)939-0666 FEE: PAD W BUILDING DEPARTMENT wwwxyLb�o0l orQ 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 ssr+rr+s*sttr+++++++rt++++t++++rt+s++++ttt+rrr+r++++++,tttrrs�+r.+r+rrr+rssrtwrrrrrwrwwwrswww+rrwrwrrwrrrrrwwrwrrs++rrrrrrr►rrr Address: v w l L t r U 0973 Occupancy/Use: _ I—FAX FAXf Parcel ID#: .�)Y, 7 3 (O Zone: GI� Owner: OCOq 151'01 ✓lv) Address:q4 a( 0 G &-oo i Y I ago P.E./R.A. or Contractor: 6 I n o l iiCqmr lj Address:1 a d 6 (ooj t p p Od w#,(r r r gm tkI r Person in responsible charge: IDQV tG � ✓ion Address: �VC) ��I eA!(' 4 i g yG dI o��/V 1105 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: tl -ZA 9 6 P4 G�I 11/) being duly swom,deposes and says that he/she resides at W (Print Name of Applicant) (No.and Street) in 1L l� D A- ,in the County of �L, 1" in the State ofX,that (City/Town/Village) he/she has supervised the work at the location indicated above,and that the actual total cost of the work,including all site improvements, labor,materials,scaffolding,fixed a uipment,professional fees,and including the monetary value of any materials and labor which may have been donated gratis was:$ 0(0.f for the construction or alteration of: t 4 d eJ"mT 60',kk a C rdUM �► Deponent further states that he/she has examined the approved plans of the structure/work herein referred to for which a Certificate of Occupancy/Compliance is sought,and that to the best of his/her knowledge and belief,the structure/work has been erected/completed in accordance with the approved plans and any amendments thereto except in so far as variations therefore have been legally authorized,and as erected/completed complies with the laws governing building construction.Deponent further understands that it shall be unlawful for an owner to use or permit the use of any building or premises or part thereof hereafter created,erected,changed,converted or enlarged,wholly or partly,in its use or structure until a Certificate of Occupancy or Certificate of Compliance shall have been duly issued by the Building Inspector as per§250-10.A.of the Code of the Village of Rye Brook./ Sworn to before me this I j Swam to before me this day of 7T//v E'l 20 day of "e'4_t e' , 20ell, _ - t Signature of Property Owner ANNA BINASCO Signature of Applicant NOTARY PUBLIC,STATE OF NEW YORK NO.01816405936 'r e , ,4 t QUALIFIED IN WESTCHESTER COUNTY Am �V G#t""'111 ISSION EXPIRES MARCH 16,2024 Print N of Prop Owner Print Name pplicant blic otary Pu 8/12/2021 �E BRC��. W � 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.iyebrook.org - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS : DATE: PERMIT# ISSUED: SECT: BLOCK: LOT: LOCATION: OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... ❑ ACCEPTED 0 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 QyE BR C 3 O� 2m 'g�}2 BUILDING DEPARTMENT ❑BUILDING INSPECTOR ASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK �J CODE ENFORCEMENT OFFICER 938 KING STREET • RYE BROOK,NY 10573 (914) 939-0668 FAX (914) 939-5801 www ryebrooLor� - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS : `� `� '"�{ `�-+ DATE: ZU�ZGZ PERMIT#�1 Y�� L ISSUED:` SECT: BLOCK: LOT: Lam .-P � NJ\ < � 7 c� LOCATION: OCCUPANCY': ❑ VIOLATION NOTED THE WORK IS... El" 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 BUILDING DEPARTMENT VILLAGE OF RYE BROOK 938 KING ET RYE BR NY 10573 L4 -0 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: 31, '- 4 , residing at, 40 6e_(1 e1AI f (Print name) (Address where you live) being duly sworn,deposes and states that(s)he is the applicant above named, and further states that(s)he is the legal owner of the property to which this Affidavit of Compliance pertains at; OCIfOt r 1 0i� , 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. r {hgnaZPrope Owne )) (Print Name of Properly Owner(s)) Sworn to before me this 17 y / ANNA BINASCO da Of I �. , 2O { NOTARY PUBLIC,STATE OF NEW YORK NO.01 B16405936 QUALIFIED IN WESTCHESTER COUNTY COMMISSION EXPIRES MARCH 16,2024 bGc) _3_ 8/12/2021 o� r o a 4 a F- M z W r4 W N w © ep C4 ZEr O � O � Q •� U Z z � Q qW6 .. V W �p z � .a °°�c a z M Q < 0 cc 00 `-' W w d w aG w e w gqlp x w 3 " a ton ° S � dr as [3Rn�Z y L BUILDING DEPARTMENT 2VILLAGE OF RYE BROOK OCTF� 2 2 2021 938 KING STREET RYE BROOK,NY 10573 (914)939-0669 1 VILLAGE OF RYE Bi=;QOK www.ryebrook.org BUILDING DEPAR-fMENT ELECTRICAL PERMIT APPLICATION Westchester County Master Electricians License Required ) FOR OFFICE USE ONL] T BP#: CQ I" EP#: CDC- (G'3 ((jj 2 5 Approval Date: 1021 Permit Fee: $ Approval Signature: AO Other: Disapproved: (fees are non-refundable) Application dated, 10 vV '960 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 withall applicable Federal,State,County and Local Codes. 1.Address: o 61 Ir hV, cV/ SBL: )2 . 73-1"- &tp Zone: .}r 2.Property Owner: P'C+14 ru L Address: Phone#: 7 p O Cell#: email: 'C r4q''710 V Pi�(Z�+'►..�C� ,y 3.Master Electrician: Address: / /1 OW (! Company Name: .(! i Address: Al 4.Proposed Electrical ork/Fixture Count: q 6 PX11 e1 a L+ L.Noi t-4 JC ew -I GU AtCho tP,4-i to I C IZ t�7d4 *wwwwwwwwwwwwwwwwwww*ww,►wwwwwwwwww*ww*wwwwwwwwwww,twwww*,rw*w**,t,r,rwww*trwww*www*www�rw**w**ww*w******sw,tw**w* STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: ��y2� 1J ru lN1t�7 ,being duly sworn,deposes and states that he/she is the applicant;bov named,and does further (print name of individual signing as the applicant) /) state that(s)he is the legal owner of the property to which this application pertains,or that(s)he is the roirb for the legal owner and is duly authorized to make and file this application. (indoye architect,contractor,agent,attorney,etc.) The undersigned further states that all statements contained herein are true to the best of his/her knowlellge 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 b rem this ✓* Sworn to be *e me this day P _ day o lsignatureof`Xroperty Owner ignature of Applicant Q r G� ANNA BINASCO I -1 NOTARY PUBLIC,STATE OF NEW YORK q 6(\j6+[yyrtn T ' N e)oPr E!Z��FIE NO.01 BICA05936 Print Nam li ant D IN WESTCHESTER COUNTYISSION EXPIRES MARCH 16,2024 lic No c 8/12/2021 Westchester Rockland Electrical Inspection Services, Inc. Phone: 914-347-3695 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 1 ;1i CITY OR VILLAGE ZIP TOWNSHI � COUNTY STRE}TEE AND NO, � ,��. /} POLE NUMBER BETWEEN N WHAT TWO CROSS STREETS IS PREMISES LOCH)�7 SECTION BLOCK LOT OCCUPANT'S NAME BUILDING OCCUPANCY nI1 P'eu CemA1? OWNER'S NAME AND ADDRESS HOME TELEPHONE NUMBER CURRENT SUPPLIED BY FROM THEIR OFFICE WORK TELEPHONE NUMBER LIST BELOW ALL EOUIPMENT WHICH YOU INSTALLED NUMBER OF OUTLETS NO.OF FIXTURES& MOTORS HEATERS OFFICE USE LOCATION LAMP RECEPTACLES ONLY SIDEWALL SWITCH INCAOE FLU ORE NO. RP EACH JVO: WATTS OUTSIDE ini i BASEMENT W4 nrT I Ino j I I U) I 1"FL. VfLL 2-FL GE OF iRYE BROOK 3' FL REMARKS:LIST OTHER ELECTRICAL DEVICES NOT SET FORTH ABOVE: 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 APPUCANT DECLARES THAT THERE IS NO OPEN APPLICATIONS FOR THE ABOVE WITH ANY OTHER INSPECTION COMPANY WREIS,INC.IS NOT LISTING,LABELING,UNDERWRITING OR CERTIFYING ANY EQUIPMENT, MATERIALS OR DEVICES WHICH ARE PERFORMED BY OTHER CERTIFIED TESTING AGENCIES OR INSPECTION COMPANIES.THE APPLICANT,OWNER,OR AUTHORIZED AGENT AGREES TO ALL THE ABOVE TERMS AND CONDITIONS AS SET FORTH FOR THE APPLICATION. SIZE OF SERVICE FEEDERS CHARACTER OF WORK NEW❑ ADDITIONAL❑ EXPOSED❑ CONCEALED❑ MUST ENTER APPLICANTS IDENTIFICATION NUMBER SERVICE ENTERS BUILDING OVERHEAD❑ UNDERGROUND E) AVOID DELAYS BY GIVING FULL AND ACCURATE INFORMATION.ALL SPACE MUST BE FILLED IN OR APPLICATION MAY BE RETURNED. NAME OF COMPANY/ ,� DATE OF APPLICATION SIGNATURE OF APPLICANT Cam. l��P /�� X S1R�ADO A TELEPHONE NO. ? CITY OR PO?[ r,A I/ C(� zip CODE�C` LK 1fE No.WFIEN APPUiCABLE WESTCHESTER ROCKLANO ELECTRICAL INSPECTION SERVICES,INC. BY THIS CERTIFICATE OF COMPLIANCE THE Westchester Rockland Electrical Inspection Services 43 North Lawn Ave, Elmsford, NY 10523 914-347-3595 `Office) 1 914-347-3596 (Fax) CERTIFIES THAT Upon the application of: Upon premises owned by: JC Toledo Dena Bruckman 42 Richmond Hill Road CT, Norwalk 06854 Located at:40 Bellefair Rd Rye Brook, NY 10573 Certificate Number: 1031564 Section:124.73 Block: 1 Lot:66 BDC: Permit Number: EP:21-268-BP:21-235 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 inion the premises at: 40 Bellefair Rd Rye Brook,NY 10573 12 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 11/04/21 Name Type Quantity Basement Reinspection-Basement ------- 1 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. 0 en N N CG U N C pl N tn to t a dr , W w 96 � w > `� tj O �. .,. _ . 00 � o Ong �rhh w ^ u Old _ V d W M� 00 Q W pC } z W cc a z F o c ~ F Fg jz a I m Z � yE 13RC�v D V 11 1l L $UIL I EPA 1 E1DD VILLAGE OF RYE OK DEC 5 2021 938 KING STREET RYE BR00 ,NY 10573 (914)9 6 914)939-5801 1/JLLAGE OF RYE BROOK BUiLOING DEPARTMENT ELECTRICAL PERMIT APPLICATION Westchester County Master Electricians License Required FOR OFFICE USE ONLY BP#: �� 3 6 EP#: �/r 3 �o Approval Date: !} �Zo Permit Fee: $ Approval Signature: Other: Disapproved: (fees are non-refundable) Application dated,/%:�'`f S'c 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. ''� I b I.Address: y ��� �✓�_ � SBL: a— r 3 ,l(1 Zone: A6 2.Property Owner:, )ZIW Address:�/© Zewz'x'�✓"e e-eo Phone#: -0 k Cell#: email �/ ✓z0'�NET 3.Master Electrician: ��/� f Cr� :4 Address:9�2 /�H Lic.#:113S Phone 4,2aW Cell#: email A01, Company Name; e -IZ46'd'0 {��C�`,�ll" _ Address/,,,�iC.y',�l1+�/1,SL 4 4.Proposed Electrical Work/Fixture Count: STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: .being duly swom,deposes and states that he/she is the applicant above named,and does further (print name of individual signing as the applicant) state that(s)he is the legal owner of the property to which this application pertains,or that(s)he is the for the legal owner and is duly authorized to make and file this application. (indicate architect,contractor,agent,attorney,etc.) The undersigned further states that all statements contained herein are true to the best of his/her knowledge and belief,and that any work performed,or use conducted at the above captioned property will be in conformance with the details as set forth and contained in this application and in any accompanying approved plans and specifications,as well as in accordance with the New York State Uniform Fire Prevention&Building Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances and regulations. Sworn to before me this Swom before me this day of 20 day OA X.j CC e. 20 � Signature of Property Owner AVWtuere of—Applicant Print Name of Property Owner Priiiitkame of Applicant Notary Public Notary g �HR! M'ELILLO Notary Public, State of New York No. 01 f�,F 16G!:S3 0-iali`led in Westch rater County Commission Expires January.,29,262a Inn 7 Westchester Rockland Electrical Inspection Services, Inc Phone: 914-�47-3595 DOPOT WRITE HERE-FOR OFFICE USE ONLY 43 North Lawn Avenue / ,� FaxA14-347-3596 Elmsford, NY 10523 � r BUILDING PERMIT NO. TEMP d DATE ) CITY OR VILLAGE l / * ZIP TOWNSHIP COUNTY--�- STREET AND NO-OR ROAD POLE NUMBER BETWEEN WHAT TWO CROSS STREETS IS PREMISES LOCATED? SECTION BLOCK LOT OCCUPANT'S NAME BUILDING OCCUPANCY OWNER'S NAME AND ADORES% A HOME TELEPHONE NUMBER CURRENT SUPPLIED BY L� FROM THEIR /f 'L 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 4NCADE FL —.NO--.II rr-.rn T TrS EACH INSPECTION OUTSIDE L� BASEMENT 1"FL DEC T5-M T-FL 3-FL ', DEPAR MENT REMARKS:LIST OTHER ELECTRICAL DEVICES NOT SET FORTH ABOVE: Ile 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 15 NO OPEN APPLICATIONS FOR THE ABOVE WITH ANY OTHER INSPECTION COMPANY WREIS,INC.IS NOT USTING,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 CONDMONS AS SET FORTH FOR THE APPLICATION. SIZE OF SERVICE FEEDERS CHARACTER OF WORK NEW❑ ADDITIONAL FI EXPOSED❑ CONCEALED fJ MUST ENTER APPLICANTS IDENTIFICATION NUMBER SERVICE ENTEHS BUILDING OVERHEAD❑ UNDERGROUND";] AVOID DELAYS BY GIVING FULL AND ACCURATE INFORMATION.ALL SPACE MUST BE FILLED W OR APPLICATION MAY BE RETURNED. NAME OF COMPANY n �. DATE OF APPLICATION SIGNATURE OF APPLICANT STREET ADDRESS TELEPHONE NO. (j � L C" MlJQ 1SJ C � �� GIC=J�J ZIP CODE LICENSE NO.WHEN APPLICABLE 11 Z J WESTCHESTER ROCKLAND ELECTRICAL INSPECTION SERVICES,INC. BY THIS CERTIFICATE OF COMPLIANCE THE Westchester Rockland Electrical Inspection Services 43 North Lawn Ave, Elmsford, NY 10523 914-347-3595 (Office) 1 914-347-3596 (Fax) CERTIFIES THAT Upon the application of: Upon premises owned by: JC Toledo Dena Bruckman 42 Richmond Hill Road CT, Norwalk 06854 Located at:40 Bellefair Rd Rye Brook, NY 10573 Certificate Number: 1032547 Section:124.73 Block: 1 Lot:66 BDC: Permit Number:EP:21-330-BP:21-235 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 inlon the premises at: 40 Bellefair Rd Rye Brook,NY 10573 Basement 1 st 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 01/11/22 Name Type Quantity Stroke Detector/Co2 Combo reinspection 1 This Certificate has been approved by Westchester Rockland Electrical Inspection Services. This certificate may not be altered in anyway. V/" ML G This certificate is valid for work performed before date of inspection only. �CC�+p�I�i�1CiC�������I�l��p�'��CI�I�I�i➢�����Ifi1�IC��l�l�i����� � m O � N o N < w w ao " ►-~ GT•1 P6 W + pip • ICI � u c O � N � 8La i ,^ Q �J O G a P-4 W � z 6I 0114, oo O ° 96 ► w o C o° r' O z 4 0o u r Z 00 ~ z Ch N u z w r w Q 4 w IT- � w a w •• o + ° Ey a1 U C a 96 u p CA r Nw o. a e D [E C IE I BUILDING DEPARTMENT NOV 18 2021 1 3D VILLAGE OF RYE BROOK VILLAGE OF RYE BROOK 938 KING STREET RYE BROOK,NY 10573 BUILDING DEPARTMENT (914)939-0668 WWW" 9&= PLUMBING PERMIT APPLICATION l FOR OFFICE USE ONLY BP#: PP#: Approval Date: NOV 1 9 1 Permit Fee: $ Approval Signature: Other: Disapproved: (fees are non-refundable) Application dated, is hereby made to the Building Inspector of the Village of Rye Brook NY,for the issuance of a Permit to install and/or 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 Federalal, State,County and Local Codes.Q \ 1.Address: To V e+l e'Fs, 9 Q,�} !`J G 54rk!k- /Vr y/U7 /3 SBL: /c)tY.73 i 1`6 Zone:/ Ub 2.Pro osed Work:: 4rpr�J( '��(`fiin�j jQl4r?1 1 75 lr^ 6�I�n�W�}• (✓1 C&14echc 1 w= ��j�,r-�G/n) o 1.11 3.Property Owner: Jn 1- ifeint/t Address: 4Lo 16C l Ar, I?d 4r��/� Phone#: 1 / ' Cell#� " email:+ . C4 G `t Pf f'&H.., 4.Masker Plumber: , tf f ! Q— Address: I�� f �Q aCL � � Lic.#: Phone#: 9/h/yp 3'—/ it#: �ff. �4�- &3 %7 email: rtlut6� Company Name: PC Al J lu roc k) Address:,RA7ti Il fix--d d0.0 1'a 4w yi� e�7 °'j7 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 ` r 1st Floor G t 2nd Floor 3'd Floor 4'b Floor 541 Floor Exterior 5.*List Other Equipment/Provide Details: Al A (Notarized Signatures Required Next 2 Pages) -1- 8/1212Q21 S f�TE OF NEW YORK,COUNTY OF WESTCHESTER ) as: I S �,AY'J lYj }j,—Y'Le being duly sworn,deposes and states that he/she is the applicant above named, (print name of individual signing as the andrer states that(s)he is the legal owner of the property to which this application pertains,or that(s)he is the for the legal owner and is duly authorized to make and file this application. (indicate architect,contractor,agent,attorney,etc.) That all statements contained herein are true to the best of his/her knowledge and belief,and that any work performed,or use conducted at the above captioned property will be in conformance with the details as set forth and contained in this application and in any accompanying approved plans and specifications,as well as in accordance with the New York State Uniform Fire Prevention&Building Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances and regulations. Sworn to before me this Sworn to before me this 1 g day of ,20 day of � ,20�_ Signature of Property Owner Sign a of Appli-catft Jv; Print Name of Property Owner Print Name of Applicant Notary Public Notary Public oz 16Z f enue vojil��uoEssiwuloO /Ltunuo aatsOOlse,M ui poililtinp 9966919H9(0'ON Mto),MeN to atstg'oi.gnd AaeloN This application must be properly completed in its entirety and must include t1f �Fdcfg '� ie �f 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 returned to the applicant. -2- sn2i2o21 STATE OF NEW YOR�K,COUNTY OF WESTCHESTER ) as: OeA`! (y q LI lm '? ,being duly sworn,deposes and states that he/she is the applicant above named, (print name of individual signing as the applicant) and further states that(s)he ips' the legal owner of the property to which this application pertains,or that(s)he is the &r G( f l�[C YI TP- n 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 r —7 Sworn to before me this day of f ,20_,k] day of C �d ��,20 Signature of Property Owner Signature of Applicant Deol 8EACIrw1�0 — 0 C44 Print Name of Property Owner Print Name of Applicant ANNA 13INASCO C�oataryftb NOTARY PUBLIC,STATE OF NEW YORK N blic NO.01BI6405936 QUALIFIED IN WESTCHESTER COUNTY COMMISSION EXPIRES MARCH 18,2024 This application must be properly completed 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 returned to the applicant. -2- 8/12/2021 • D QEWE BUILDING DEPARTMENT [NOVS 2Q2� VILLAGE,OF RYE BROOx 938 KING STIMET RYE BPooy,,NY 10573 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��OpF"NEW YORK,jC�OUNTY OF WESTCHESTER ) as: { /� 31, "_l `-�y L Lt G l 4 M`� ,residing at, -t i (' 9 d f ti t o r 0 d! (Print name) (Address where you live being duly sworn, deposes and states that(s)he is the applicant above named, and further states that(s)he is the legal owner of the property to which this Affidavit of Compliance pertains at; 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. 1w VJ (Si tune of Property Owner(s)) D e-rn g 9 r L.&i[ a� (Print Name of Property Owner(s)) t Sworn to before me this day of (Notary Public) SHARI MELILLO Notary Public, State of New York No. 01 tA17616"CO3 O-_ialiT:ed in Westchester County Commission Expires January 2.9.20 -3- 8/12/2021 i T � C a X O ac ou ■ a Crc N F i' x W V � � w .r O L ' C � � Z '2 > Q y 00 C r `' .= - -a - 106 C3 F O Y t CZZ > o z � e1 ON M R O +yr � � � O W o °00 ON ON 2 F O/ C W y FF�11 en T a M u _ Fit N zgg v � � F ' v yoc cac W Z `L N 06 N a W) 0 13 A � EE g. cc W, Www BUILD MENT VIL E OF R OK D D 938 KING � ET RYE BR NY 10573 SEP - 8 2021 (914)9 9 39-5801 �, �, VILLAGE OF RYE BROOK BUILDING DEPARTMENT APPLICATION TO INSTALL FIRE SUPPRESSION / FIRE SPRINKLER SYSTEM FOR OFFICE USE ONLY:Approval Dates Er 1 Application Fee:$ 6 r /06 Approval Signature: Permit Fees:$ Disapproved: Other: Application dated: 40 is hereby made to the Building Inspector of the Village of Rye Brook NY for the issuance of a Permit to tnstall or modify Ta Fire Suppression/Fire Sprinkler System as per detailed statement described below. 1. Job Address: �� Ql�` !"� I ' wr' !U -1 le'V3 2. Parcel I.D.: Z)Y, 73 — Zone: Pu/S 3. Proposed Work(Describe system in detail including suppression agent): C� f 4. Number&Types of Fire Sprinkler Heads: ,� f e/l Cn �( 5. N.Y State Construction Classification: Asl C1++4 N.Y. State Use ClasstTcation: r �'► _ 6. Estimated Value of Job: (Value shall include all labor,materials,tixcd�,equipment,professional flees,and materials and labor which may be donatcd gratis.) 7. Property Owner: 0 tji G f&(4 (,�tq f n Address: xi- A J Phone# Cell#J�4_ �� O?W lemail: &A�t—'(.Prd va t.4, A1�_ Applicant: $ fi►,t{ _ Address:. Phone# Cell# email: Architect/Engineer: Address: Phone# Cell# email: General Contractor: NeL 6z- a ProlrcAyn.�e(V/pelddress: 417 AWgee—,Weep` /veil Vel Phone# Cell# �/j�—a/7 8�� email: eT ef11Z 4J- This application must be properly completed 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. Any application not properly completed in its entirety and/or not properly signed shall be deemed null and void and will be returned to the applicant. Please note that application fees are non-refundable. STATE OF NEW�}e4 YO K,COLiNTY OF WESTCHESTER ) as: g AA V1-4c+r/)7f-1 , being duly sworn,deposes and states that he/she is the applicant above named, (print name of individual signing as the applicant) and further states that (s)he is the legal owner of the property to which this application pertains, or that (s)he is the for the legal owner and is duly authorized to make and file this application. (indicate architect,contractor,agent,attorney,etc.) That all statements contained herein are true to the best of his/her knowledge and belief, and that any work performed, or use conducted at the above captioned property will be in conformance with the details as set forth and contained in this application and in any accompanying approved plans and specifications,as well as in accordance with the New York State Uniform Fire Prevention & Building Code, the Code of the Village of Rye Brook and all other applicable laws,ordinances and regulations. Sworn to before me this d t Sworn to before ine this y 1 Adav 20 day of 20e of Property Owner ANNA BINASCO tNnature of Applicant NOTARY PUBLIC, BLIC,STATE OF NEW YORK �/ ("�_ QUALIFIED IN WESTCCHES ER COUNTY 1.�f"l Jq�v Print Name of Pro Owner COMMISSION EXPIRES MARCH 16,2024 Property Print Name of Applicant rotary Public RyPubhc 2 1 3il't11u Laura Petersen From: David Bruckman <dbruck4@verizon.net> R Sent: Tuesday, August 17, 2021 9:03 AM 'D To: Laura Petersen Subject: Fwd: L&L Backflow Prevention Testers - Test Results [AUG 1 2021 Attachments: Bruckman - SN 876952 (e09984) - 2021-08-17.pdf VILLAGE OF RYE BROOK BUILDING DEPARTMENT Here is the backflow results. Making some progress -----Original Message----- From: LnLBackflowPreventionTesters@gmail.com To: dbruck4@verizon.net Sent: Tue, Aug 17, 2021 8:40 am Subject: L&L Backflow Prevention Testers-Test Results Administration Staff, Attached is the 1013 Test Sheet on Device 876952 for Bruckman located at 40 Belfair Road Port Chester, NY 10573. The test was performed on 8/17/2021 and the outcome of the test is_. If you have any questions, please contact my office at 914-937-4784. Regards, Leo N. Dragani NY Cert# 04189 i i t 09984 NEW uOR Public DEPARTMENT OF ction HEALTH Report on Test and Maintenance Bureau of Public Water Supply Protection Empire State Plaza-Coming Tower Room 1110 Albany.NYt2237 of Backflow Prevention Device Please use a separate form for each device. For the year 2021 ❑ Initial test- Complete entire form Annual test-Complete Part only Publk Water Suppry Account No. County Bock Lot Facility Name Bruekman Location of Device Basement Meter Closet Address 40 Betfair Road Port Chester,NY 10573 Street City Zip Device Manufacture Type Type ❑ RPZ Model Size(in inches) Serial Number Information Willuns/Zarn ® DCv 950XL 1 876952 CM&Main No.1 Cheek Valve No.2 Differential Prassure Relief Line Pressure 90.0 osl Valve Leaked Leaked ® Opened at paid Date Trore Closed tight Closed tight 08 17 21 Mpgh Pressure drop across first check valve M D Y paid Dsserlbei Repaired by repairs and Name medwisla used Lic# Date repaired: M D Y Final lost I Closed tight ❑ Closed tight ❑ Opened at paid Date Pressure drop across first check valve paid M D Y Water Meter Number Meter Reading Type of Service:(check one) 54814395 014238936 ❑ Domestic ® Fire ❑ Other Remarks(Describe deficiencies:bypasses,outlets before the device,connections between the device and point of entry,missing or Inadequate alrgaps,etc.) Certification:This device 0 meats, 0 does NOT meet,the requirements of an acceptable containment device at the time of testing I hereby certify the foregoing data to be correct. Leo N.Draeatid 04189 0 6/30/2024 Print Name Certified Tester No. Signature Expiration Date Property owner's(or owner's agent)certification that test was performed: David Bruekman Homeowner _ (914)92"864 Print Name Title Signature Telephone Certification that installation is in accordance with the approved plans. (To be completed by the design engineer or architect or water supplier.) I hereby certify that this Installation is in accordance with the approved plans. Name Tile Date m ❑ NYS DOH Log# License Number Phone( ) m d y Representing Describe minor installation changes Address City State Zip Signature NOTE:Send one completed copy to the designated health department representative and one copy to the water supplier within 30 days of the testing device. Notify owner and water supplier immediately if device falls test and repairs cannot Immediately be made. DOH-1013(9191) REcE 'YE DI FUN - 9 2021 Richter Engineering , P.C. VILLAGE OF RYE BROOK BUILDING DEPARTMENT 115 Cedar Hill Road, Bedford, NY, 10506 Phone: 914-907-3895 E-Mail: ericdetmer@richterengineering.com ATTN: Village of Rye Brook Building Inspector DATE: 08 June 2021 FROM: Eric R. Detmer, P.E. SUBJECT: 40 Bellefair Road, Rye Brook, NY inspected the fire sprinkler in the basement at the above-mentioned address. The fire sprinkler system is installed in accordance with the 2020 New York State Residential Building Code, the 2020 New York State Fire Code and NFPA 13D-2016. Respectfully submitted, ©� NEW Y ` n n �d p frd239N �. ��F s E,,S40� Eric R. Detmer, P.E. Building Permit Check List&Zoning Analysis Address: O L` aL t— rL �Zn . SBL Zone.�1 Use: Const.Type: Other: t-E-4&L l -L A o Submittal Date: D Zl Revisions Submittal Dates: 2 l f 10 Z Applicant: Nature of Work LF�G ALL ''N_ CrvU�>� �� _72 oo + ghat.+ tX'4-,0 w Reviews:ZBA• MAR 1 1 2021 PB• BOT• Other. (11F_F ( ) FEES:Filing- 7S' BP: 7 - C/O: Legalization: 3 t �— {> ( APP: Dated: Notarized: SBL: ✓tmm I.D. Cross Connection; ✓ H.O.A.: z { ] ( ) Scenic Roads: Steep Slopes: Wetlands: Storm Water Review: Street Opening. ( ] ( ) ENVIRO: Long. Shorn Fees: N/A: { ] ( ) SITE PLAN:Topo: Site Protection S/W Mgmt.: Tree Plan: Other. ( ] ( ) URVEY:Dated: Current: Archival: Sealed: Unacceptable: ( ) {�LANS:Date Stamped ✓ Sealed: —" Copies:_7�- Electronic: Other. License: ,--*,Workers Comp: + Liability: � Comp.Waiver. Other. ( ) ( } CODE 753#: LA/3/—CXK_ Dated/ N/A: HIGH-VOLTAGE ELECTRICAL:Plans: Permin N/A: Other: ( ) ( ) LOW-VOLTAGE ELECTRICAL:Plans: Pernun 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: Per min Fuel Type: Other. O { ) 2020 NY State ECCC: N/A: Other. ( ] ( ) Final Survey Final Topo: RA/PE Sign-off Letter. As-Built Plans: Other. ( ) { ] BP DENIAL LETTER: C/O DENIAL LETTER: Other: ( ) ( ) Other: { )ARB mtg.date: approval: notes: ( )ZBA mtg.date: approval: notes: ( }PB mtg.date: approval• notes: APPROVED REQUIRED EXISTING PROPOSED NOTES n P R 1 3 2021 Asp'. Date. ►i Circle: Frame Fronn Fmnt: &d.0- lam: Main Cov Accs.Cov F S Sd.H/Sb a Tot I n: Parking Ha"/Stories: notes: 1 0 � : � JOHN G. SCARLATO JR. ARCHITECT 33 Byram Hill Road Armonk, N.Y. 10504 Phone: (914) 273-7350 Fax: (914) 273-9222 JGSCARLATO@GMAIL.COM 4/7/21 Mike lzzo Building Inspector Village of Rye Brook 938 King Street D �� �n Rye Brook, NY 10573 dJ APR - 8 2021 Dear Mike: 1 DD VILLAGE OF RYE BROOK RE: 40 Bellefair Road BUILDING DEPARTMENT Enclosed is one 24 x 36 and one I I x 17 copies of revised drawings show a new egress window in place of the exiting window on the side wall of the house. We are getting a approval letter form the homeowner association. If you have any questions or need anything else, please give rune a call. Thank you for your help. Sincerely, John G. Scarlato Jr. L 'fjr� �f//�m�'axrr'r Ar��f nrWt L[• R S C 1� � V E HrW /D rrerrn Illy 74 S.D.F—WM1&8Jr 8—.L N.Y.Jff77 April 21, 2021 MAY 10 2021 0 VILLAGE OF RYE BROOK BelleFair ARB BUILDING DEPARTMENT 24 Bellefair Blvd Rye Brook, New York 10573 Dena Et David Bruckman 40 Bellefair Road Rye Brook, New York 10573 Re: Legalization of Basement Dear Dena Et David, We write in response to your request to the ARB for approval of the legalization of your basement situated at 40 Bellefair Road, Rye Brook, New York. We are pleased to inform you that based on the details of your application, your application has been approved. Once this project is complete contact our FirstService representatives, Rafael Reyes or Michael Napolitano so that a final inspection may take place. Please be advised that our approval will be expressly conditioned upon your continued compliance with Schedule D of the Declaration, Accordingly, if the aforementioned fails at any time to comply with the Regulations, the ARB reserves the right to direct modification or the removal of the improvements at your sole expense to ensure compliance. Please note that approvals are valid for one year as of the date of this letter. As a reminder, certain alterations will require the approval of the Village of Rye Brook's Building Inspector or Engineer. You shall be responsible for obtaining all required approvals and permits. The Village of Rye Brook will consider applications after BelleFair ARB approval is given. The Village of Rye Brook approval does not preclude the need for ARB approval, nor does ARB approval relieve you from any responsibility of obtaining Village of Rye Brook approval If you have any questions, please do not hesitate to contact us. Very truly yours, The BelleFair Architectural Review Board Laura Petersen From: Laura Petersen Sent: Thursday, May 13, 2021 11:16 AM To: John G.Scarlato,Jr. Subject: Building Permit Application -40 BelleFair Road - Legalize Finished Basement Attachments: Fire Suppression Full 6.1.2020.pdf Good morning John, I don't have any contact information for the homeowner at 40 BelleFair Road. We will need the following items before I can process the permit; `f1. General contractor's contact name & phone number. 41),�Ao-iy Ca✓npc)S . Copy of general contractor's valid Westchester County Home Improvement License. General contractor's valid liability insurance (the Village Of Rye Brook must be the certificate holder) A. General contractor's valid workers compensation on a NY State Board form (C105-2 or / U26.3) pjI jjc?✓J,?y M1c. ✓ 5. Fire sprinkler application & fee ($75.00 application fee and permit fee $15.00 per $1,000.00 or a minimum of$100.00) (See attached) A6. Fire sprinkler contractor's liability insurance (the Village Of Rye Brook must be the / certificate holder) ✓ . Fire sprinkler contractor's workers compensation on a NY State Board form (C105-2 or U26.3) 8. Building permit fee $375.00 and Legalization fee $3,000.00 (due at the time of pick up) Please let me know if you can provide the homeowner's email and/or forward this email. Thank you! Laura Laura Petersen Office Assistant Village of Rye Brook .�V�CLAI 938 King Street (,LA L+`�" Rye Brook, New York 10573j Phone(914)939-0668 1 Fax(914)939-5801 1 Ipetersen(Qryebrook.ora JI >-DO O's r Laura Petersen From: David Bruckman <dbruck4@verizon.net> Sent: Tuesday,June 8, 2021 6:21 PM To: Laura Petersen Subject: legalization of basement. Bruckman.40 Bellefair Rd Attachments: Letter to Bldg Inspector re 5prinkler.pdf Hi Laura. We spoke a few weeks ago and I have your letter to John Scarlato regarding my project. I am interviewing contractors as my usual guy unfortunately is undergoing chemo. I will let you know when I have one and will submit their info, ins, etc for the permit application. I was able to get the sprinklers signed off on. Please see aAttached letter from the sprinkler engineer. Thanks. David 1 Laura Petersen From: Laura Petersen Sent: Thursday,July 29, 2021 10:50 AM To: David Bruckman Subject: 40 BelleFair Road - Fire Sprinkler Application and Plans Attachments: Fire Suppression Full 6.1.2020.pdf Good morning, After speaking with the Assistant Building Inspector regarding the fire sprinkler sign off letter, a fire sprinkler application and fire sprinkler plans are still required for the basement legalization. v 1. Fire sprinkler application & fee ($75.00 application fee and permit fee $15.00 per $1,000.00 or a minimum of$100.00) (See attached) V. Fire sprinkler contractor's liability insurance (the Village Of Rye Brook must be the certificate holder) ,/3. Fire sprinkler contractor's workers compensation on a NY State Board form (C 105-2 or U26.3) Please let me know if you have any questions. Thank you Laura Laura(Petersen Office Assistant Village of Rye Brook 938 King Street Rye Brook, New York 10573 Phone(914)939-0668 1 Fax (914)939-5801 1 Ipetersen(i)ryebrook.org T*- HZ L ­--la"1 N RLFI-1 A4CC>RO DATE(MMIODIYYYY) 1111%. � CERTIFICATE OF LIABILITY INSURANCE 08/23/2021 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 endorsements. PRODUCER 203-268-9999 acT John M.Rodrigues John Rodrigues Ins.Assoc. PHONE 203-268-9999 FAX 203-2614436 Monroe Insurance Center Inc. C.No,Ertl: PJC,No: 501 Main Street Monroe,CT 06468 John M.Rodrigues INSURE S AFFORDING COVERAGE NAIL 0 INsnRERA:Admiral Insurance Company INSURED INSURERS:National Grange Mutual 14788 NI�R L Fire Protection Services A Pepper Street INSURER C: Monroe,CT 06466 INSURER D INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBEIRO REVISION NUMBERR 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 SU vivo POLICY NUMBER POLICY EFF POLICY EXP LJYIT'S A X COMMERCIAL GENERAL LIABILRY 1,000,000 EACH OCCURRENCE CLAIMS-MADE [X]OCCUR X CAe0002433pd16 05117/2021 05117/2022 DAMAGE TO RENTED 50,000 MED EXP(Any one ersm 5,000 X Designated Con Pr 1,000,000 PERSONAL 8 ADV INJURY GENII AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 111 2,000,000 POLICY JECT LOC PRODUCTS-COMPIOPAGG 2,000,000 OTHER: B AUTOMOBILE LIABILITY COMBINED accidnijSINGLE LIMIT 1,000,000 E.X ANY AUTO B2T1103U 05117/2021 05/1712022 BODILY INJURY Perperson) OWNED - SCHEDULED AUTOS ONLY AUUTNOQSW D BODILY Pag� INJURY Per accident S A" S ONLY A7JTOS ONt�Y aE nt AGE UMBRELLA LIAR OCCUR EACH OCCURRENCE EXCESS LIAR CLAIMS-MADE AGGREGATE DIED RETENTION$ B WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITYSTATUTE FR B ANY PROPRIETORIPARTNER/EXECUTIVE YIN WCP4723V(CT) 05117/2021 05117/2022 E.L.EACH ACCIDENT 500,000 Ifr. 'I)nBEREXCLUDED7 � N/A WlP4723V (NY) 05117/2021 05/17/2022 500000 (('f�MS descreberNunder E.L.DISEASE-EAEMPLO D SCRIPTION OF OPERATIONS500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached tf more space Is required) Certificate holder included as additional insured. CERTIFICATE HOLDER CANCELLATION VILLRYE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Village of Rye Brook, NY THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN g y ACCORDANCE WITH THE POLICY PROVISIONS. 938 King Street Rye Brook,NY 10573 AUTHORIZED REPRESENTATIVE /' John M.Rodrigues 4_C2kVA1a_ 0,44 4j ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD YOR Workers' CERTIFICATE OF STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured 203-395-3300 N R L Fire Protection Services Inc. 472 Pepper Street Monroe,CT 06468 1c.NYS Unemployment Insurance Employer Registration Number of Insured 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 201023368 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Main Street America Village of Rye Brook 938 King Street 3b.Policy Number of Entity Listed in Box"la" Rye Brook,NY 10573 W 1 P4723V 3c.Policy effective period May 17,2021 to May 17,2022 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 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: Laura wolff (Print name of authorized representative or licensed agent of insurance carrier) AApproved b �` � ® APPMED PP y j 4b LW*WN M-60 m,A-A&20." (Signature) (bate) Title: Account Executive Telephone Number of authorized representative or licensed agent of insurance carrier. 203-268-9999 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 ! Y w:{� �_!• ' "a•' • 1 .J/"` " ' r•—•� __ate_\ .pry-. ` C .. - - - - �.}•� � i � yr' •y � M Eta ,� A?,_'• CL cm ci OAw II' �..,f CL �+��"`�.•,�•i it Cori O � y Ak o 's v di3 o . ,• W5 LL ` A Q 112 40 nj 40 tu y QA '. ge AC R V CERTIFICATE OF LIABILITY INSURANCE DATEIMMIDDIYYYY) `� 07/1312021 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 poilcy(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 endorsementis). PRODUCER CONTACT NAME: Kathryn Payola Avanti Associates PHONE (g i14)273.8511 914 273-B05D Ara No: 200 Business Park Dr ADDRIL ESS: kathy®avanfiassociates.com Suite 206 INSURER(S)AFFORDING COVERAGE NAIC e Armonk NY 10504 INSURER A: Main Street America Assurance 29939 INSURED INSURER a: ANTHONY CAMPOS INSURER C: d/b/a ANTHONY C COMPANY INSURER D: 100 WHIPPOORWILL RD E INSURER E ARMONK NY 10504-1463 INSURER F COVERAGES CERTIFICATE NUMBER: CL213961550 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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. LTR TYPE OF INSURANCE I POLICY NUMBER MMIDDIYYYY) (MMIDR= LIMITS COMMERCIAL GENERAL UABIL(TY EACH OCCURRENCE $ 1,D00,000 CLAIMS-MADE ®OCCUR PREMISES Ea oc"rencelt S 500,000 MED EXP(Arty one person) ; 10,000 A MPV92352 10/03/2020 10/0312021 - PERSONAtdADV INJURY S 1.000,000 GENT AGGREGATE LIMtT APPLIES PER: GENERAL AGGREGATE ; 2,000,000 POLICY ,ECT I.00 PRODUCTS-COMP/OPAGG S 2,000,000 OTHER: $ AUTOMOBILE LIABILITY CO MBINE LIM $ ANY AUTO -(Ea acddenl BODILY INJURY(Per person) S OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Par sadden) S HIRED AUTOS NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY fper ; $ UMBRELLA UAB OCCUR EACH OCCURRENCE S EXCESS UAa CLAIMS-MADE -- H AGGREGATE E DED RETENTION; WORKERS COMPENSATION S AND EMPLOYERS'LIABILITY PER CIT YIN STA TE ERA ANV PROPRIETORIPARTNER/EXECUTIVE (Mandatory In NH) EXCLUDED? ❑ N 1 A E.L.EACH ACCIDENT f (Mandatory In NH) If yea,describe under E.L.DISEASE-EA EMPLOYEE S DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (ACORD 101.AddttlorW Remarks Schedule,may be attached N more apace is required) Job Location:40 Bellefair Road,Rye Brook,NY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Engineering&Public Work Village of Rye Brook ACCORDANCE WITH THE POLICY PROVISIONS. 936 King Street AUTHORIZED REPRESENTATME Rye Brook NY 10573 __ �, r 01988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(201 W03) The ACORD name and logo are registered marks of ACORD ym Workers' Certificate of Attestation of Exemption STATE Compensation from New York State Workers' Compensation and/or Board Disability and Paid Family Leave Benefits Insurance Coverage "This form cannot be used to waive the workers'compensation rights or obligations of any party." The applicant may use this Certificate of Attestation of Exemption ONLY to show a government entity that New York State specific workers'compensation and/or disability and paid family leave benefits insurance is not required. The applicant may NOT use this form to show another business or that business's insurance carrier that such insurance is not required. Please provide this form to the government entity from which you are requesting a permit,license or contract. This Certificate will not be accepted by government officials one year after the date printed on the form. In the Application of Business Applying For: (Legal Entity Name and Address): Building Permit ANTHONY CAMPOS From:Village of Rye brook 10573 Building Dpt DBA:ANTHONY C COMPANY 4 Sanswept Dr New Fairfield,CT 06812 The location of where work will be performed is PHONE:203-546-8105 FEIN:XXXXX9382 40 Bellefair Rd,Rye Brook,NY 10573, Estimated dates necessary to complete work associated with the building permit are from July 29,2021 to October 15,2021. The estimated dollar amount of project is 50-S10,000 Workers'Compensation Exemption Statement: The above named business is certifying that it is NOT REQUIRED TO OBTAIN NEW YORK STATE SPECIFIC WORKERS'COMPENSATION INSURANCE COVERAGE for the following reason: The business is owned by one individual and is not a corporation. Other than the owner,there are no employees,day labor,leased employees,borrowed employees,part-time employees,unpaid volunteers(including family members)or subcontractors. Disability and Paid Family Leave Benefits Exemption Statement: The above named business is certifying that it is NOT REQUIRED TO OBTAIN NEW YORK STATE STATUTORY DISABILITY AND PAID FAMILY LEAVE BENEFITS INSURANCE COVERAGE for the following reason: The business MUST be either: 1) owned by one individual; OR 2) is a partnership(including LLC,LLP,PLLP,RLLP,or LP)under the laws of New York State and is not a corporation; OR 3) is a one or two person owned corporation,with those individuals owning all of the stock and holding all offices of the corporation(in a two person owned corporation each individual must be an officer and own at least one share of stock); OR 4) is a business with no NYS location. In addition,the business does not require disability and paid family leave benefits coverage at this time since it has not employed one or more individuals on at least 30 days in any calendar year in New York State. (independent contractors are not considered to he employees under the Disability and Paid Family Leave Benefits Law.) 1,ANTHONY CAMPOS,am the Sole Proprietor with the above-named legal entity. I affirm that due to my position with the above-named business i have the knowledge,information and authority to make this Certificate of Attestation of Exemption. I hereby affirm that the statements made herein are true,that 1 have not made any materially false statements and I make this Certificate of Attestation of Exemption under the penalties of perjury. I further affirm that I understand that any false statement,representation or concealment will subject me to felony criminal prosecution,including jail and civil liability in accordance with the Workers'Compensation Law and all other New York State laws. By submitting this Certificate of Attestation of Exemption to the government entity listed above i also hereby affirm that if circumstances change so that workers'compensation insurance and/or disability and paid family leave benefits coverage is required,the above-named legal entity will immediately acquire appropriate New York State specific workers'compensation insurance and/or disability and paid family leave benefits coverage and also immediately furnish proof of that coverage on forms approved by the Chair of the Workers'Compensation Hoard to the government entity listed above. SIGN I HERE Signature: Date: .— `Z 7 , Exemption Certificate N ber Received 2021-044524 July 14, 2021 NYS Workers'Compensation Board CE-200 01/20t8 Laura Petersen From: Dig Safely New York Exactix <tickets@exactix.digsafelynewyork.com> Sent: Monday, September 13, 2021 10:51 AM To: Mike Izzo Subject: Message from Dig Safely New York, Inc. (DSNY) ****REGULAR**** DIG REQUEST from DSNY for: VIL RYE BROOK Taken: 09/13/2021 10:49 To: VIL RYE BROOK PRIMARY Transmitted: 09/13/2021 10:50 00002 Ticket: 09131-001-231-00 Type: Regular Previous Ticket: ------------------------------------------------------------------------------ State: NY County: WESTCHESTER Place: RYE BROOK Addr: From: 40 To: Name: BELLE FAIR RD Cross: From: To: Name: Offset: ------------------------------------------------------------------------------ Locate: RIGHT SIDE OF PROPERTY AS FACING, FACING THE FRONT NearSt: HIGH POINT CIR & FELLOWSHIP LN Means of Excavation: SHOVEL Blasting: N Site marked with white: N Boring/Directional Drilling: N Within 25ft of Edge of Road: Y Work Type: INSTALL EGRESS WINDOW Estimated Work Complete Date: 09/23/2021 Depth of excavation: 12 INCHES Site dimensions: Width 4 FEET Start Date and Time: 09/16/2021 07:00 Must Start By: 09/30/2021 ------------------------------------------------------------------------------ Contact Name: ANTHONY CAMPOS Company: ANTHONY C COMPANY Addr1: SUNSWEMP Addr2: City: FAIRVIEW State: CT Zip: 06812 Phone: 914-403-4775 Fax: Email: toto01957@hotmail.com Field Contact: ANTHONY CAMPOS Alt Phone: 914-403-4775 Working for: HOMEOWNER ---------------------------------------- ------------------------------------- Comments: Lookup Type: PARCEL ----------- ------------------------------------------------------------------ Members: ALTICE USA CONED : SUEZ WTR WESTCHESTER VIL RYE BROOK WESTCHESTER CTY SWR i Uuld JdPlUDIJUS dJI� 41!118-tiV9LOZ a��—dd3N ja 1�1 uijdst aa.j l,ZOZ Isn6ny l 1, :aleQ ,0' =,8/a also leul6!a aainbaa jou saop (,9'ZX,9*6 `•11 •bs S O �aoM ou uiouaa� ' as aaanbs �a un aso o `aouoa ua a3IAJ;9s 6ui six 2Z) -VZ P 10 uo!jeaalle aqj jo uo!}duosep oilpeds a pue } .� . 3 _ uoijeaalle eons jo alep auj pue ain}eu6!s s!u Aq paMolloj„Aq pajalleli a oaIDUI51JOuoi a ou a ue eas si 6uinne.� si o xi e e s.�aau�6ua 6uiaa e I S . . .� u p I .U p .u� I I u 1I auj `paaalle s! 6u!Meip sigl uo Dual! ue 11 -AeM Cue u! 6u!Meip siql go L (S 4-V 6� C� c uo wal! 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