Loading...
HomeMy WebLinkAboutBP21-244PERMIT # SECTION . TYPE OF I JOB LOCp OWNER a CONTRAC' 91 COST #� DATE: r; ►C,& At/l— �rMooeelW =it1.5r7L�P�°�C�fE'sNc�l�rian �IrQZ (9iy��i 037y DA TCO it FEE DATE ._ _ _ INSPECTION RECORp DATE FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING C] RGH PLUMBING GAS 0 SPRINKLER ELECTRIC LOW -VOLT CO ALARM AS BUILT O FINAL INSP OTHER APPROVALS ARB - PB - - Z43A - . 19 VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Paul S. Rosenberg (914) 939-0668 Christopher J. Bradbury www. ebrr ook.org TRUSTEES BUILDING& FIRE Susan R. Epstein INSPECTOR Stephanie J. Fischer Michael J. Izzo David M. Heiser Jason A. Klein CERTIFICATE OF COMPLIANCE October 25,2021 Suzanne Elson&Marie Mazzone 111 Brush Hollow Lane Rye Brook,New York 10573 Re: 111 Brush Hollow Lane, Rye Brook,New York 10573 Parcel ID#: 129.76-1-149 Building Permit#21-244 issued 9/28/2021 to Rebuild Wall Damaged by Hurricane Ida This certifies that the entire mesa block wall,rebuilt under the above captioned permit has been satisfactorily completed. Sincerely, Michael J. Izzo Building&Fire Inspector Itg E `C• E N E 1tTNiENT For office use onlv: BUILDINt ' PERMIT#� OCT 18 2021 V LIB OF RYE 0K IssuED: c ! 938 KING STREFT,4�tYE BROOX, `EW YORK 10573 DATE: VILLAGE OF RYE BF�oOK 10,�4}9 -Q - FEE: VykyEb PA a BUILDING L EPARTME=t',1T a k:4t' 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 �012C-o Address: j S Lain xz�— K j. AN l0f Z Occupancy/Use: ff Parcel ID#: Zone:� �--� 46— Owner: smtia,�LSovl 4-I bap j CL mLt;zZD Address: P.E./R.A. or Contractor: ¢dFess:lck'] �a kj.�Stf, Qe QL Person in responsible charge: A4 P,i GL,.i PE:: 7 Addddress:11 —A4 LSt 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: SATIATE OF NEW YORK,COUNTY OF WESTCI�ESTER as: SlJ 7-C an.v%e-C4 $DVS being duly sworn,deposes and says that he/she resides at UI L)s fh No Uoc.1,3, (Print Name of Applicant) (No.and Street)in l 3 rl,yYao LL in the County of o— in the State of AfY that (City/Town/Village) he/she has supervised the work at the location indicated above,and that the actual total cost of the work,including all site improvements, labor,materials,scaffolding,fixed equipment,professional fees,and including the monetary value of any materials and labor which may have been donated grads was:$ 3.15 QC) // + for the construction or alteration of: c� Ti r TQ 4 n ,yl C1, L,O 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 ib Sworn to before me this day of O , 20 .:L day of , 20 SignafiCR of P erty Owner Signature of Applicant y�[11n Ul 1�1 Print Name of Property Owner Print Name of Applicant Notary Public SHARI MELILLO Notary Public Notary Public,State of New York No. 01 ME6160063 8/12/2021 O!aalified in Westchester County Commission Expires JantJgry 29 20 '2� DRCZj,�. BUILDING DEPARTMENT ;'BUILDING INSPECTOR ASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK. ( ❑CODE ENFORCEMENT OFFICER 938 KING STREET - RYE BROOK, NY 10573 (914) 939-0668 FAX (914) 939-5801 www ryebrook.org - - - - - - - --- -- - - - - - -- - INSPECTION REPORT - - - - - - - - - - - - - - - -- - - - ADDRESS : f r2 .� t4 �„ DATE: / 3 LZ Z 2 PERMIT# T�I- Li �ISSUED: SECTS ' BLOCK: LOT' t LOCATION: f - � Ctil (A ALL OCCUPANCY: 4 r' ❑ VIOLATION NOTED THE WORK IS... Ef ACCEPTED ❑ REJECTED/ REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ NATURAL GAS ❑ L.P! CAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION FINAL OTHER a a - N ,� N N ,,,,// oG � v G ■ eq w 52 bp aw ,4 p 'd rh ■ rj CL O -- � V O O=r A . , 04 lil W w W w W IT0*4 � °� ca = O �I A � � Q w G O � � � •o ,� � a � oc W 0.0 w d � U U A � M E-� o W a � � � � ❑ � � � .� a moo, �•-� W Q � 0o � � � M� a � rA .� � � � � oc �.y N A W V V O R O O b4 C 1� FTs CZ Ui w z o � � a bU �-, ►� Ln z h o odo � � � Q Hgbt a U U v 8 0 Co ■ BUILD TMENT SEP 2 3 2021 VIL QI` OOK 938 KING _ NY 10573 VILLAGE OF RYE BROOK 4j99-0 ' BUILDING DEPARTMENT 196'2 ADMINISTRATIVE EXTERIOR BUILDING PERMIT APPLICATION FOR EXTERIOR WORK WHICH DOES NOT REQUIRE VILLAGE ARCHITECTURAL REVIEW BOARD APPRON'Ai. FOR OFFICE USE ONLY: QQ 1 APPROVAL DATE: O O�I M1T#' _Q)LI APPLICATION FEE: APPROVAL SIGNATURE: PERMIT FEES: H.O.A.APPROVAL: � ) DATE: 1it DISAPPROVED: OTHER: )OIV e Application dated: is hereby made to the Building Inspector of the Village of Rye Brook,NY,for the issuance of a Permit for the construction of buildings,structures,additions,alterations or for a change in use,as per detailed statement described below. 1. JobAddress: ( f _ 2. ParcelID#: Zone:U� L Z �fir, -- l — l �"�.�[ /pl}� 131 Ircosed Improvement(Describe in detail): 4. Property Owner t J�� Address: 1`� Q ���r l� Phone# tP �l J Cell# —�Q — L� n� e-mail �L�L @ List All Other Properties Owned in Rye Brook: T�-Ipp l'VQ Q Applicant: Z ii Address: ,ry IA CIO Phone# � t.(,iC1�� Cell#�1cS (�(� ]41 e-mail( ` catt Architect: M 1 C Q Address: Phone# Cell# e-mail Engineer: Address: Phone# Cell# e-mail General Contractor: r L�C Address k Phone# : Cell# c mail t (I) 8/12no21 • Post-construction: 5. Occupancy;(1-Fain.,2-Fain.,Commercial.,etc...)Pre-construction: 6. Area of lot: Square feet: Acres: 7. Dimensions from proposed building or structure to lot ling front �f--tr�Ie� right side yard: left side yard: c7�f 8. If building is located on a comer lot,which street does it front on: 9. Area of proposed building in square feet: Basement: I'fl: 2°d fl: 3'a 10, Total Square Footage of the proposed new construction: 11. For additions,total square footage added;Basement: it °d 31d fl: 12. Total Square Footage of the proposed renovation to the exis cture: 13. N.Y. State Construction Classification: N.Y. State Use Classification: 14. Construction Type&Location: ()Typical Western Lumber Frame;()Timber Frame[TC];()Wood Truss[TT]; O Pre-engineered wood[PW];Located;O Floor Framing[F];O Roof Framing[R];O Floor&Roof Framing[FR];Other; 15. Number of stories: Overall Height: Median Height: 16. Basement to be full,or partial: finished or unfinished: 17. What material is the exterior finish: 18. Roof style;peaked,hip,mansard, shed,etc: Roofing material: 19. What system of heating: 20. If private sewage disposal is necessary,approval by the Westchester County Health Department must be submitted with this application. / 21. Will the proposed project require the installation of a new,or an extension/modification to an existing auto fire suppression system? (Fire Sprinkler,ANSL System,FM-200 System,Type I Hood,etc...)Yes:_No:_V (if yes,applicant must submit a separate Automatic Fire Suppression System Permit application&2 se of detailed engineered plans) 22. Will the proposed project disturb 400 sq.ft. or more of land,or create 400 sq.ft.or more impervious coverage requiring a Stormwater Management Control Permit as per§217 of Village Code? Yes:—No:—Area: 23. Will the proposed pr ' ct require a Site Plan Review by the Village Planning Board as per§209 of Village Code? Yes: No: (if yes,applicant must submit a Site Plan Application, &provide detailed drawings) 24. Will the proposed project require a Steep Slopes Permit as per§213 of Village Code Yes: No: (if yes,you must submit a Site Plan Application, &provide a detailed topographical survey) 25. Is the lot located within 100 ft.of a Wetland as per§245 of Village Code? Yes: No: (if yes, the area of wetland and the wetland buffer zone must be properly depicted on the survey&site plan) 26. Is the lot or any portion thereof located in a Flood Plane as per the FIRM Map dated 9/28/07? Yes: No: (if yes,the area and elevations of the flood plane must be properly depicted on the survey&site plan) 27. Will the proposed project require a Tree Removal Permit as per§235 of Village Code?Yes: No: (if yes,applicant must submit a Tree Removal Permit Application) 28, Does the proposed project involve a Home-Occupation as per§250-38 of Village Code? Yes: No: Indicate;TIER I: TIER II: TIER III: (if yes,a Home Occupation Permit Application is required) 29. What is the total estimated cost of construction: S Note.'estimated cost shall include all site improvements, labor,material,scaffolding,fixed equipment,professional fees,including any material and labor which may be donated gratis.If the final cost exceeds the estirn �edcost,an additional fee wildtie required prior to issuance o the C/o. 30. Estimated date of completion: r ti }'�} CIJ �- � 21ECFW/ D PD BUILD Sip Z 3 2021 MENT VIL OF: OOK 938 Knvc ET ftr,S ` NY 10573 VILLAGE OF RYE BROOK 4 BUILDING^DEPARTMENT AFFIDAVIT OF COMPLIANCE VU,LAGE 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: �. )c b r�r Q� 1 rt. resi ' g at, 1 (Print name) 4A4 he a you live) being duly sworn, deposes and states that(s)he is the�c avnarhed, anurther states that(s)he is the legal owner of the property to which this Affidavit of Compliance pertains at; ' _ll y 1lt5v) N<A i c_)LL Lafl_ , 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. (Signature of Property Owner(s)) (Print Name of Property Owner(s)) Sworn to before me this / sV day of to r' , 20�,(A] (Notary lic) JUDI L.PAGE-MELAGRANO Notary Public,Stele of New York No.OIPA5053772 Qualified in Westchester County (3) Commission Expires 8/12/2021 This application must oe properly completed in its entirety by a N.Y. State Registered Architect or N.Y. State Licensed Professional Engineer & signed by those professionals wine;e indicated. It must also 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. r*wwwwwww•wwwwwwwwwwwwwr,rwwwt*t*w*ww+r*******wwwwww,►w,rwwwwwr*,r,+******w*w**wwww*w**,r,r***w,r,rw,r**w+***,�ww*+*�,r STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: J ZCLv\ln j2,, J: t 6 nv-,,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. By signing this application, the property owner further declares that he/she has inspected the subject property, and that to the best of his/her knowledge there are no roof drains, sump pumps or other prohibited stormwater or groundwater connections or sources of infiltration into the sanitary sewer system on or from the subject property. Sworn to before me this 3" Sworn to before me this day of �2t , 209 \ day of , 20 Signature 0 roperty Owner Signature of Applicant 1 � (2- 7 rr v�1a�_ ` -5 Print Name of Property Owner Print Name of Applicant c Notary Public ALEXANDRA H.MARSHALL Notary Public,State of New York No.011FR6363711 Qualifled In Westchester County Commission Expires August 28,20 �? BUILDING DEPARTMENT D VILLAGE OF RYE BROOK OCT 8 2021 938 KING STREET'RYE BROOK,NY 10573 (914)93 ..-0668 VILLAGE GE RYE BROOK wwHr•r�. ol . r BUILDING DEPARTMENT_ FOR OFFICE USE ONLY: o Approval Date: OCT $ 2021 e it �� � Application# Approval Signature: ARCHITECTURAL REVIEW BOARD: Disapproved: : Date: BOT Approval Date: Case# Chairman: PB Approval Date: Case# Secretary: ZBA Approval Date: Case# Other: Amendment Fee: _jkb)Ved—,14Permit Fee:Ak)V'e4C�'Z APPLICATION TO AMEND APPROVED PLANS Application dated: —00—Q/ is hereby made to the Building Inspector of the Village of Rye Brook,IVY,to amend the approved plans associated with an existing open permit,and/or from any prior approvals granted by the approval authority as per detailed statement described below. I. Job Address:_1�9, VStI N',64)LL)�—(. ftoy V7jV_ k1 Existing Permit#: IB(Pl( `A+ 'L r 2. Parcel ID#: 3 0- 1 L T Zone: "PL�D Original Approval Date: LI 9 j 3. Proposed Amendment(Describe in detail): 'p,b t Cad- �� i UYl�f 70 Lf 4. Property Owner: 11 Q— E_ S eA vj M,LJ IC eC_' M _Z 7-- nvA,0 Address: h—Q 1 Phone# ?`4 0 c1Q -9 3_3 3 Cell# / _b � � /� e-mail r ry) Zz. 3 3-�4e Witt C oaN Applicant. U C� _ Address: LO �_Ct (L Abu Phone# 7 i 620 `V 3 3 ?j Cell# I/'y__-3 1 ----I SL 7 Architect/Engineer: Address: Phone# Cell# e-mail 5. Occupancy;(I-Fam.,2-Fam.,Comm.,etc...)Prior to construction: After construction: 6. Will the proposed amendment require the installation of a new,or an extension/modification to an existing automatic fire suppression system? (Fire Sprinkler,ANSL System,FM-200 System,Type I Hood,etc...)Yes: No: (_(if yes,you must submit a separate Automatic Fire Suppression System Permit application&2 sets of detailed engineered plans) 7. Will the proposed amendment disturb 400 sq.ft.or more of land,or create 400 sq.ft.or more of impervious coverage requiring a Storm water Management Control Permit as per§217 of Village Code?Yes: No:�( Area: 1 8/12/2021 r • 8. Will the proposed amendment require a Site Plan Review by the Village Planning Board as per§209 of Village Code? Yes: No: )( (if yes,you must submit a Site Plan Application,&provide detailed drawings) 9. Will the proposed amendment require a Steep Slopes Permit as per§213 of Village Code Yes: No:.K_(if yes,you must submit a Site Plan Application,&provide a detailed topographical survey) 10. Is the lot located within 100 ft of a Wetland as per§245 of Village Code? Yes: No:X(if yes,the area of wetland and the wetland buffer zone must be properly depicted on the survey&site plan) 11. Is the lot or any portion thereof located in a Flood Plane as per the FIRM Map dated 9/28/07? Yes: No: (if yes,the area and elevations of the flood plane must be properly depicted on the survey&site plan) 12. Will the proposed amendment require a Tree Removal Permit as per§235 of Village Code?Yes: No:-X_(ifyes,you must submit a Tree Removal Permit Application) 13. Does the proposed amendment involve a Home-Occupation as per§250-38 of Village Code? Yes:_No:,L-If yes,indicate: TIER I: TIER II: TIER III: (if yes,a Home Occupation Permit Application is required) 14. Will the proposed amendment result in additional square footage to the building or subject structure,and if so,provide such additional footage here. (Please submit additional Bulk Regulation Application Pages for review) 15. What is the total added cost of the work associated with the amendment: $ 31000 (The estimated cost shall include all site improvements,labor,material,scaffolding,fixed equipment,professional fees,including any material and labor which may be donated gratis.) 16. N.Y.State Construction Classification:/ N.Y.State Use Classification: 17. Estimated date of completion: 10 /,JS a This application must be properly completed In its entirety by a N.Y. State Registered Architect or N.Y. State Licensed Professional Engineer&signed by those professionals where indicated. It must also 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. e***rr*r*r**r****w,r*,r,r*•,t+r..*,t,rw,r*r****,t.******************x**,t*,t,t*,t*�*,r**,r*************�r**************,t*** STATE OF NEW YORICOUNTY OF WESTCHESTER ) as: t)Z o v\tA�o_ i in In ,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. By signing this application,the property owner further declares that he/she has inspected the subject property,and that to the best of his/her knowledge there are no roof drains, sump pumps or other prohibited stormwater or groundwater connections or sources of infiltration into the sanitary sewer system on or from the subject property. Sworn to before me this T1111 Sworn to before me this day of ,20�L day of , 20 SipAll of Prope Owner�` Signature of Applicant j I--,v=6r "y\e L -\ Print Name of Property er Print Name of Applicant Notary Public 2 ALEXANDRA H.MARSHALL Notary Public,State of New York No,01FR6363711 Qualified In Westchester County Commission Expires August 28,20-2L 8/12/2021 :%FFII)A\'17' IN SUPPORT OF FEE W:1IVER RELATED TO 14URRICANE IDA S"I ATF 01: N&J Vo rk COUNTY OF We5�C sdt°_+,­ ��,f� tnsert name►, being duly sworn. deposes and says I. I am the applicant fora Building Permit . Certificate of'Occupancy / Detnolition Permit Electrical Permit Plumbing Permit / Fence & Wall Permit \Mechanical Permit Pod Permit (circle all that apply) 1.2. I am the legal owner of property located at I11 �)y txl )ham _ " Rve Brook. New York (insert street address)QR I am the (Are hi fee tTontractor/l rtgineer/A Ito rncy) (circle one) for the leg I c�r of p9 located at _ _ Rye Brook,New York and I am duly authorized by property owner to make and fife the accompanying application. 3. The following is a description ot'(1) the work to be performed under the permit tier �01ch I am applying: and (2) hog% the work arose as a direct result of t[urricane Ida: 4. The %\ork describe herein arose as a direct result of Hurricane Ida and does not include Work %%hich \ as not caused b\ I lurricane Ida. Sworn to before me this r [)ay o ' ?tt�L "Jut r Public NO Jtar i .Pic,staeofNo York Notary Public, State of New York No.0JPA5053772 ()uamed in Westchester County commission Expires ,:-,j , ID] Sip 2 3 2021 VILLAGE OF RYE BROOK BUILDING DEPARTMENT Building Permit Check List&Zoning Analysis Address: L L L,�w SBL: Z� (-� - C -- ( q j Zane: Use: Const.Type: Other: Submittal Date: Revisions Submittal Dates: Applicant: 0 t.3 rj7 Nan of Work:�' N l c..-1, R_,� �— e Reviews:ZBA:S E P 2 8 2021 PB: BOT: Other: NEED OK ( ) {,,, ' TES:Filing: BP: 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: I N/A: ( } ( } SITE PLAN:Topo: Site Protection S/W Mgmnt.- 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: ( } ( ) 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: { } ( ) PLUMBING Plans: Permit: Nat. Gas: LP Gas: N/A/: Other. { ) ( ) FIRE SUPPRESSION:Plans: Permit: N/A: Other. ( } { ) H.V.A.C.: Plats: 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 tncg. date: approval: notes: APPHOVLU UOU[RED Fxrsrnvc; PROPOSED N©TES Date: S E P 2 8 2021 Fro From l� Main cov Accs.Cov Ft.H � CIE& TOL imp H notes: zm 2 % 4 � � § 2 • ® 7Lf LU . } E c _ # A 5 g § § \ ce 2 } a M / § ■ tu � � U � w § _ § w % k 0 \ C i ■ k q > k j LU A / p Ee z = 2 - 3 ! § \ 2 § K\ . / CA \ d 2oE z> k :E w 2 & � 2 u= » o (U �_ � } ~ $ ) � 250 § E q k w f » kt � ; 2\§ . 19 w w E ui § \ § � i $ � 2 =& § } . a 0 Jk 9119121,7:34AM IMG_1949.jpg iPAW " a/ ►1!`i. 14�• https:hmail.google.com/mailfulQl?ogbl#inboxJFMfcgzGljvNLshhzRMQTxNQBIFvVtBjz?projector=1&messagePartld=Q.3 ir1 9/19121,7:30 AM IMG_1948.jpg for i s � i.. �c htips://mail.google.com/maiUu/0/?Ogbl#inbox/FMfcgzGljvN Lsh hzRMOTxNQBiFvVtBjz?projector=1&messagePartld=0.1 1!1 9119121,T32 AM IMG_1952.jpg �r II P �i1 A �ir►}fir � `a �' . i. https:llmail.google.comlmaiVu/Ql?ogbl#int>ox/FMfcgzGljvNLshhzRMQTxNQBIFvVtBjz?projector=i&messagePartld=4.5 111 n- {U T O O C; (6 L 44 C V% a0 19 J Ln O O •O � � 2Z LL z N y N Q� C ii 00 � Y) O l0 m CL 0 Nj �' 0 O z j ti2 m LU 2 V' YU. 0 o © o � � o a. r oC W v �..- z } >- CL =) o } ti LLJ z V) 0 '° E w o r o uj U) z L.L v c� OMn Z w c I - p z ui � z o •- o � I = -v L.Yji \ r V) 0 c o z .. �.. E 6p cn ..� E }y ♦�//�� � _. ca o : I C Ry a C _� O Cr G OL C3 U w Z d _Q O _ CL N v © y c C.) C 0 a a W y ra -2Q a 3E -- - m so M W �, — E r w L� O O C -Q -5 0 c2 O co Qy p C c as E p. Q7 C E Q b qy X E C -E C vl wa o > N <t d > m a o CZ ro H p a c n a U X a Q Q m 0 ,�«�1>� .__"' i',.}Ila. ..:• ::.,11 }i ^f -., Y -.: l�,{!1 .:. air":l1I1; ; i k: °a M . ,. tCo)s' 1/ a 21 '2 .N tO cm Vr " d U _ O i cr LL I o � .. f w , IWO > W `n c o f: r ice► O W O o '= Lecti©n �t f � W tb W J '� Lu c t� co0 Q to L 1 @� +.� Lh Y u G7� O V V W UJ .r 14 \ J 4 a o due adLU atu :r� CN 7- owlILlu { taRs)> h",wt .. .. - i AC®0 DATE iMMroomYY) CERTIFICATE OF LIABILITY INSURANCE 09f2412021 THIS CERTIFICATE 1S 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: Hiscox Inc. PHONE (888)202-3007 FgI�C No: 5 Concourse Parkway E-MAIL Suite 2150 ; oantaat@hisc ox.Com Atlanta GA,30328 INSURER 8 AFFORDING COVERAGE NAIC 0 INSURERA. Hiscox Insurance Company Inc 10200 INSURED INSURER 9: PEREZ M&W HOME IMPROVEMENT LLC 1215 PARK ST INSURERC: PEEKSKILL,NY 10566 INSURER 0, INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INSR TYPE OF INSURANCE ADDL SUB POLICY EFF POLICY EXP LiMrr3 LTR POIJCYNUMBER MWlDD MMIDD_ X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE ,1XI OCCUR PREMISES Ea occurrence $ 100,000 MED EXP(Any one person) $5,000 A N UDC-4611114-CGL-21 09/23/2021 09/23/2022 PERSONAL&ADV INJURY $ 1,000,000 707HER: LAGGREGATELIMITAPPLIESPER: GENERAL AGGREGATE $2,JEC 000,0G0 POLICY II LOC PRODUCTS-COMPIOPAGO $2,000,000$ UUNILIIY COMBINED SINGLE LIMIT AUTOMOBILE L $ _ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE _ AUTOS ONLY AUTOS ONLY r exldent UMBRELLA LIAR OCCUR EACH OCCURRENCE � EXCESS LUIB HCLAIMS-MADE AGGREGATE $ DIED RETENTION$ $ WORKERS COMPENSATION PER 4TH- AND EMPLOYERS"LU\BILITY YIN STATUTE ER _ ANYPROPRIETORIPARTNENEXECUTIVE 7 NIA E.L.EACH ACCIDENT $ OFFICERIVEMBEREXCLUDED7 (Mandatory In NH) E-L.DISEASE-EA EMPLOYEE $ f yyes,describe under DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES(ACORD 101,Additional Remarks Schedule,may oe attached If more space Is required) CERTIFICATE HOLDER CANCELLATION THE VILLAGE OF RYE BROOK 938 KING STREET SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE RYE BROOK NY 10573 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE :f O 1988-201 S ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD NEW Workers' CERTIFICATE OF sTATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured PEREZ M &W HOME IMPROVEMENT LLC 914-618-0374 DBA/TA PEREZ M &W HOME IMPROVEMENT LLC 1215 PARK ST 1c.NYS Unemployment Insurance Employer Registration Number of Insured Peekskill, NY 10566 N/A 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 85-3120492 2.Name and Address of Entity Requesting Proof of Coverage 3a.dame of Insurance Carrier (Entity Being Listed as the Certificate Holder) ?National Liability & Fire Insurance Company VILLAGE OF RYE BROOK 3b.Policy Number of Entity Listed in Box"1 a" 938 KING STREET N9WC222397 Rye Brook, NY 10573 3c.Policy effective period 03/17/2021 to 03/17/2022 3d.The Proprietor,Partners or Executive Officers are included.(Only check box If all partners/officers included) 7 all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box 1"insures the business referenced above in box"1 a"for workers' compensation under the New York State Workers'Compensation Law. (To use this form, New York(NY)must be listed under Item 3A on the INFORMATION PAGE of the workers'compensation Insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"2". The insurance carrier must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail.)Otherwise,this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent,or until the policy expiration date listed in box"3c",whichever is earlier. This certificate is issued as a matter of information only and confers no rights upon the certificate holder. This certificate does not amend, extend or alter the coverage afforded by the policy listed, nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Workers'Compensation contract of insurance only while the underlying policy is in effect. Please Note: Upon cancellation of the workers'compensation policy Indicated on this form, if the business continues to be named on a permit, license or contract issued by a certificate holder, the business must provide that certificate holder with a new Certificate of Workers' Compensation Coverage or other authorized proof that the business Is complying with the mandatory coverage requirements of the New York State Workers' Compensation Law. Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: Rakesh Gupta (Print name of authorized representative or licensed agent of Insurance carrier) Approved by: _ � I�,(} =Y 09/24/2021 3 (Date) Title: Chief Operations Officer Telephone Number of authorized representative or licensed agent of insurance carrier: 844-472-0967 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 ¢ s r o 13 ^^ FILE COPY w 00 sue) 'u 1 L c { 'J C R t _ � � - rJ 4 J I'a w zt- Lo ry � c, r ) L# (c> — L © TE AP v o SEP 2 8 7021 r. 1 t J i 8 llD1NG iN i'EC illag�aEq�� MGM► I I , L �— ._ o } cn ix W U-0 �ti 1�N - -- _ iu i 43 LL r I� La a a u_ s � A IV Ad- vo,. m I� oz w u a:I U C ro oc� w Wj IL �9 t Q VLlZ ~ OIL ❑ ZD � 4 x � m z ` , o` Z W F21