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HomeMy WebLinkAboutBP21-249PERMIT # SECTION TYPE OF WORK JOB LOCAAT'I JO--N _ OWNER/7 CONTRACT EST. COST CO #� - DATE% .3v a / E.xP.- ©� BLOCK LOT �y r rlam AEI gpi �/ c� . ale%Q /uc� /y)��� /?/v i/ors 6e� /C'© OYbi Ll� �Qs�r� ,�uegj �l7ij���l 03/3 S; (oc�jv1— INSPECTION RECORD 1 DATE INSP FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING RGH PLUMBING GAS SPRINKLER ELECTRIC LOW -VOLT C7 ALARM AS BUILT CJ FINAL /-.> q91 arkv;eW C/ec,�ical OTHER APPROVALS BOT ZBA OTHER VILLAGE OF RYE BROOK WESTCHESTER COUNTY, NEW YORK No: 22-033 Certificate of Occupancy This is to certify thatOhro+npher Delvro £ Doolenla Delaco of, R)(e.> Bmn k, L y having duly filed an application on P-v a0f20 C5?(q— requesting a Certificate of Occupancy for the premises known as, Rye Brook,NY, located in a Zoning District and shown on the most current Tax Map as Section: /3 J. Block: Lot: and having fully complied with the requirements of the Building Code and the Zoning Ordinance under Building Permit No.Oq — 1 / issued `�! o 20 02 /, 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: cc v one- an? -1v for the following purposes: kepol,r u r 0 Subject to all the privileges, requirements, limitations and conditions prescribed by law, and subject also to the following: This certificate does not in any way relieve the owners or any person or persons in possession or control of the premises, building,or any part thereof from obtaining such other permits or licenses as may be prescribed by law for the uses or purposes for which the building or premises is designed or intended. Furthermore, it does not relieve such owners or persons from complying with any lawful order issued with the object of maintaining the premises or building in a safe and lawful condition. No changes or rearrangement in the structural parts of the building or in the exit facilities shall be made, and no enlargement, whether by extending on any side or by increasing in height s 11 be made,nor shall the building be moved from one location to another until a permit to accomplish such change has b o in d€rom-t wilding Inspector. Building Inspector,Village of Rye Brook: Date: MAR 10 �� ��3�.�3 For office use only: D E C E��E BUILDINGS E'&TMENT PERMIT# /Q 1/9 DD VILLAGE OF RYE BROOK ISSUED: "�j-30 -a 1 FEB 2 4 2022 938 KING STREET,RYE BROOK,NEw YORK 10573 DATE: �— y— (914)939-0668 FEE: O I Ved PAW 0 VILLAGE OF RYE BROOK www,ryeebrook.org BUILDING DEPARTMENT 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 iitttffififff#if#ilitt#ifiiiitiittti•offici#ff###iiitifffffi#iittiiittttfif►#iiff#fif#iittitittiiiiiii###iiii#t#iiiiifftitiif Address: Occupancy/Use: NET�(V\O _ Parcel ID#: Zone: Ownero1 r �4Y�L4�cs� l J l`Lt CCUAddress: 1 !�; L9 e-A$,7 9 P.E./R.A. or Contractor: Rom- -C CL Address: 19gr — tNo(:-rvt i-f �A` Person in responsible charge:.JRVZT SQi►U0`Ak 6-&F--V'&--Address: sc�a- N o'g4K S'T W<r'�'�►`�° �a(D�� Application is hereby made and submitted to the Building Inspector of the Village of Rye Brook for the issuance of a Certificate of Occupancy/Certificate of Compliance for the structure/construction/alteration herein mentioned in accordance with law: STATE OF NEW YORK,COUNTY OF WESTCHESTER as: being duly sworn,deposes and says that he/she resides at ��rE>Y(:>C)1G L�, (Print Namme )o) --e of Applicant) (No.and Street) 1 in O,P. 1 t r in the County of in the State of�,that (City/Town/Village) he/she has supervised the work at the location indicated above,and that the actual total cost of the work,including all site improvements, labor,materials,scaffolding,fixed equipment,professional fees,and including the monetary value of any materials and labor which may have been donated gratis was:$ 1 L" (6�' t0co , for the construction or alteration of: Qev"P 'q' s y Q e TO S'T O 'CZ Y'N Q.A•/- p' 4--er 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 structuretwork 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 Sworn to before me this day of 20 day of , 20 G c Dom., t.. e Signature of Property Owner Signature of Applicant t' pv�ST�E'E Q- vev-) c'X i Name of Property Ow ne c' Print Name of Applicant Notary Public Notary Public SHARI MELILLO Notary Public, State of New York Nlo.01?hE 6160063 8/12/2021 Oualified in Westchester County Commission Expires January 29,20 QyE BRC�,,�. BUILDING DEPAR rMENT ❑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: , \ �O 1 1►G(�! C? DATE: PERMIT# � _ " ISSUED: SECT: BLOCK: LOT: LOCATION: �—�\ `� ="��" y` OCCUPANCY: L ❑ 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 cs-�1 ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ .CROSS CONNECTION FINAL ❑ OTHER �yE BR(�jk. BUILDING DEPARTMENT ❑Bu*PING INSPECTOR AS 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• c `- DATE: PERMIT# ISSUEDT 3 ? SECT: BLOCK: LOT: LOCATION: d< OCCUPANCY: Z ❑ VIOLATION NOTED THE WORK IS... /ACCEPTED ❑ REJECTED/REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ I,TNDERGROUND PLUMBING NOTES ON INSPECTION: r. ROUGH PLUMBING ❑ ROUGH FRAMING INSULATION 'f ❑ NATURAL GAS ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER • 00 _ dp � N e N � M to O = Y v p`2 d O mot Y F- �i W o LLI OF oo 19 p z w LL! ciwil = W Z w Z � A u � Z r••y � �" a OC mo ° = < W w o Q = N � � N E h� Q O W oc 96 Gr 0 L w OZ W I- a Q 3 � d � W6 2 «�� dR�ox BUILDIN&1Sii"TMENT SEP 2 4 2021 VIL AGE OF RYE BROOK 938 KnvIREET RYE F ,NY 10573 VILLAGE OF RYE BROOK (914) BUILDING DEPARTMENT www.ry._ r9 ELECTRICAL PERMIT APPLICATION Westchester County Master Electricians License Required FOR OFFICE USE ONLY BP#: QD - a Y 9 EP#: C>� / Approval Date: Permit Fee:: $ Approval Signature: Other: 24—�)V e --ZF—N1Q Disapproved: (fees are non-refundable) Application dated, "WC)J is hereby made to the Building Inspector of the Village of Rye Brook NY,for the issuance of a Permit to install and/or remove electrical equipment,wiring, fixtures,or to perform other high or low voltage electrical work as per the detailed statement described below. The applicant & property owner, by signing this document agree that all electrical work performed will be in conformance with all applicable Federal,State,County and Local Codes. 1.Address: �ri �d0 L� SBL: �� Zone: �40,—JO 2.Property Owner: �RN\ l_{� t LL�c� Address: �J L-N Phone#: Cell#: 9� —01.-) `4G&7 email: 3.Master Electrician: )V\NANI�Zz \W)�\5\ Address: y-lO Lic.#: (AZ\ Phone#:gky,/yip•2L1—LS Cell#: g��- Company Name: l-c yD FX— \\x Addressy"1:� \c ,_,5v\eM N\)- 4.Proposed Electrical Work/Fixture Count: �'\—) C STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: tlp kAg-0 t" kUJ 6 k 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 lllrly` QZ N-I I J`S) for the legal owner and is duly authorized to make and file this application. (indicate architect,contractor,agent,attorney,etc.) The undersigned finther 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. Swom,L4efoke me th' � Sworn befo e me this day qf 20 day of s Signature of Property Owner Signature of Applicant 1, PLkKC> tAKL\► 1S t Name of Property Rwner F4jt Name of AppIica * Notary Public Notary Public SHARI MELILLO SHARI MELILLO . Notary Public,State of New York Notary Public, State of New York No.01 ME6160063 No. 01 ME61 G0063 Ouali ied in Westchester County OualiTied In Westchester County Commission Expires J-•�uary 29 203 Commission Er-Ires J­-,uary 29 20 8/12/2021 Q� ka IVA —ILCA Westchester Rockland Electrical Inspection Services, Inc. Phone: 914-347-3595 DO NOT WRITE HERE-FOR OFFICE USE ONLY 43 North Lawn Avenue Fax: 914-347-3596 ` 4;7 Elmsford, NY 10523 BUILDING PERMIT NO. TEMP# DATE CITY OR VILLAGE ZIP CODE TOWNSHIP COUNTY STREET AND NO.Ofi ROAD POLE NUMBER BETWEEN WHAT TWO CROSS STREETS IS PREMISES LOCATED? SECTION BLOCK LOT OCCUPANT'S NAME BUILDING OCCUPANCY OWNER'S NAME AND ADDRESS HOME TELEPHONE NUMBER CURRENT SUPPLIED BY FROM THEIR OFFICE WORK TELEPHONE NUMBER LIST BELOW ALL EQUIPMENT WHICH YOU INSTALLED NUMBER OF OUTLETS NO.OF FIXTURES& MOTORS HEATERS OFFICE USE LOCATION LAMP RECEPTACLES ONLY SIDEWALL SWITCH INCADE FLUORE NO. H.P.EACH NO. WATTS EACH INSPECTION OUTSIDE BASEMENT 1'FL. 2'FL. 3'�FL. VI LAGE F RYE BROOK G DEPMRTIV 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 APPLICANT DECLARES THAT THERE IS NO OPEN APPUCATIONS 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 f 1 CONCEALED❑ MUST ENTER APPLICANTS IDENTIFICATION NUMBER SERVICE ENTERS BUILDING OVERHEAD❑ UNDERGROUND 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 STREET ADDRESS TELEPHONE NO. CRY OR POST OFFICE LP LICENSE NO.WHEN APPLICABLE AFFIDAVIT IN SUPPORT OF FEE WAIVER RELATED TO HURRICANE IDA STATE OF V�e�`�,r%,— COUNTY OF� ��t's � c1� e�2 W.LA (insert name), being duly sworn, deposes and says 1. I am the applicant for a Bu ' Permit/Certificate of Occupancy / Demolition Permit lectrical Permit Plumbing Permit/Fence & Wall Permit Mechanical Permit/ Pod Permit(circle all that apply) 2. I am the legal owner of property located at v-UU\r-- Lc1 Rye Brook,New York (insert street address) OR I am the (Architect/Contractor/Engineer/Attorney) (circle one) for the legal owner of property located at �S 'e)\(-DC7 L L y-\ , Rye Brook, New York and I am duly authorized by property owner to make and file the accompanying application. 3. The following is a description of(1) the work to be performed under the permit for which I am applying; and (2) how the work arose as a direct result of Hurricane Ida: 4. The work described herein arose as a direct result of Hurricane Ida and does not include Work which was not caused by Hurricane Ida. Sworn to before me this D\A- Day o "� r, 20� Notary Public SHARI MELILLO D V Notary Public,State of New York V No. 01 f T61-00 3 0,iatF`:ed in Westchester County SEP 2 4 2021-- JD ' Commission FXt)irPS,�• ��a�,�q 2n'a-3, i VILLAGE OF RYE BROOK BUILDING DEPARTMENT 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: Parkview Electrical Christopher& Daniela Deluca 470 Halstead Avenue suite 3E NY, Harrison 10528 Located at: 15 Brook Ln Rye Brook, NY 10573 Certificate Number: 1033050 Section: 135.65 Block: 1 Lot:24 BDC: Permit Number: EP:21-248-BP:21-249 A visual inspection of the electrical system at this premise described as a Residential occupancy,wherein the premises electrical system consisting of electrical devices and wiring,described below,located in/on the premises at: 15 Brook Ln Rye Brook,NY 10573 Basement 1st Floor 2nd Floor 3rd Floor Garage Attic Outside Other: Inspection was conducted in accordance with the NYS and NFPA 70-2017 International Electrical Code and detail of the installation,as set forth below,was found to be in compliance therewith on 02/23/22 Name Type Quantity Receptacle Convenience ------- 25 Switch Single Pole ------- 5 Receptacle GFCI ------- 5 Fixture-Luminaire Recessed LED 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. II" G��� r i ��. f 16 �p r � ■ N N f py C O f a — owl U s' f kaWl $, 96 r "M7 ON 01 � � coAC4 � Q U O o z 0 oZO*A � 00 v v z � � o f Ono 0 -.. qT c N : p.� a Q 6 rw z c rz 3 - i A a w w � �j a a go go ago PCE- MIE 3D BUILDING DEPARTMENT OCT - 1 2021 VILLAGE OF RYE BROOK 938 KING STREET RYE BROOK,NY 10573 VILLAGE OF RYE BROOK (914)939-0668 BUILDING DEPARTMENT www.ryebrook.org PLUMBING PERMIT APPLICATION FOR OFFICE USE ONLY BP#: C;) 9 PP#: OCT - I M1 Approval Date: A Permit Fee:: S Approval Signature: NAN Iq 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 Federal,State,County and JL�ocal Codes. 1.Address: %S B�oD,� L/�Al SBL:/J i&5-/""a 7 Zone: 2.Proposed Work: 045&0NA4'r_7- Ati0 Alar74,A-d�3 {RUC 7o SToA-A,' OAMA6�& 76 ,�Yazl! � 3.Property Owner: C11tZ43 fa pb'" C)e1--uGA Address: /S G X-o-04 G4 Jl/Br Phone#: !i/y— qc:�— I&to7 Cell#: email: 4.Master Plumber: A?ZwV eA11 f/t AVALG d6 Address: /07 1/' AjCW5 /1 fill AIWAel, J 1 Lic.#: li_9 Phone#: Cell#: 9/ -7.sS-073 3 email: L'Y"I.54ITN1A.14LANoMAtie CoOA4 Company Name: LANDM^7L X- &oPji iK C T_sb," Address: /ate IW n PCe5 /rye 1y0f# 2-Sb)J /y f /05;P4 INDICATE FIXTURES&LINES TO BE INSTALLED AS PER THE FOLLOWING SCHEDULE: Location Water Urinals Drinking Sinks Showers Bath Laundry Domestic Fire Sanitary Natural/ Other* Total Closets Fountains Tubs Tubs Service Service Sewer LP Gas Basement 1st Floor .L , 2nd Floor 31 Floor 41 Floor 5t6 Floor Exterior 5.*List Other Equipment/Provide Details: fk."A rb-r- a-A rA-71 (Notarized Signatures Required Next 2 Pages) 4- 8/12/2021 STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: 0y4J. r'OQ qCV- Dee U eing 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. C Sworn to before me this Z Sworn to before me this day of ,20 a t day of G C\t> -f ,20� Signature of Property Owner Signature of Applicant Cameo'e c!X �jcd7t Ol ti�!N e1f1/112/1 t//9 L b K Print Name of Property Owner 41rint Name of Applicant tary Pub C JOHN F MCKENNA , State of New York Notary Public.state of New York No. 01 PAE6160063 No.01MC6348996 Qualified in Westchester County Qualifiedmis to Expires ter county Commission Exoires Jpnuary 29 20� My Commission Expires Oct 1 t,2024 This appli o u e proper y 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- si12i2021 BUILDING DEPARTMENT DST - ZOZ1 VILLAGE OF RY&ftOOK ID 938 KING SET Rx B� 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 OF NEW YORK, COUNTY OF WESTCHESTER ) as: 'D 11i�W,:A ,residing at, (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; 15;- S k- ,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 ,—) ( JOHN F MCKENNA l Notary Public.State of New York day of }�� , 20 I NO.01MC6348996 Qualified in Westchester County My Commission Expires Oct 11,2024 (N Public) -3- 8/12/2021 AFFIDAVIT IN SUPPORT OF FEE WAIVER RELATED TO HURRICANE IDA STATE OF �- �vLI� COUNTY OF (insert name), being duly sworn, deposes and says 1. 1 am the applicant for a Building Permit/Certificate of Occupancy/Demolition Permit Electrical Permit/Plumbine Permit/Fence & Wall Permit Mechanical Permit/Pod Permit(circle all that apply) 2. 1 am the legal owner of property located at S 'gx�' � Rye Brook,New York (insert street address) OR I am the (Architect/Contractor/Engineer/Attorney) (circle one) for the legal owner of property located at 1 �C�o� , Rye Brook, New York and I am duly authorized by property owner C+'lti4�Ta to make and file the accompanying application. 3. The following is a description of(1)the work to be performed under the permit for which I am applying; and (2)how the work arose as a direct result of Hurricane Ida: OA Iq QG r �vC / 5 fd/L� �2arrls /pGtii e1u/LeS 124rVn P- (A,/it -S IA.,g 4. The work described herein arose as a direct result of Hurricane Ida and does not include Work which was not caused by Hurricane Ida. Sworn to before me this Z- 9 Day , 20 2-1 `�L JOHN F MCKENNA Notary Public-State of New York Notary Public N0.G1MC6348996 Qualified in Westchester Cou 2y24 MY Commission Expires Oct 11, OCT I 1 2021 j I VILLAGE OF RYE BROOK BUILDING D-E-PARTNIENT ismoi n . A w 1 6 ° 0 ; cI m c �lP71 I ad O vL0 RawSO J W `� �✓�� � section _ Z a LU / f _ 4-40N 1` ' O U) rn a. 4) .w cc r�'. • 4 R: L :.? O C>.1 o `; • 1,•,•,�' �'J11�111,1. E gg a J r. ' . . . . . . . . . h-; Eli (ss)> #;? � �' ^,` '•'•'' ,�I���4 'itil,�ll�i'��� %+J,IN, -. .` 4,�„1 _ :t-�„�,,,'..;,a �=s:>,J,Ilhlh,� �+'r,.. �' v �J •.• d i 1 � �d.0�' Y �,I,I,,,�i _r ,III/I,�,� Iltil' �,, _. ACORO® DATE(MM/DD/YYY`n C" CERTIFICATE OF LIABILITY INSURANCE 09/24/2021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: FAX Hiscox Inc. PHONNo,E IAIC. . (888)202-3007 - --(A/C No): -- -- 5 Concourse Parkway E-RE Suite 2150 SS: contact@hiscox.Com - - Atlanta GA,30328 INSURERS AFFORDING COVERAGE NAIC8 INSURER A: Hiscox Insurance Company Inc 10200 INSURED — INSURER B: — Art Builders General Contractors LLC 892 North Street INSURERC: White Plains,NY 10605 INSURERD: 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 ADOL SUBR POLICY EFF POLICY EXP LIMITS LTR POLICYNUMBER MM/DD MWDD X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE f 1,000,000 DAMAGE TO RENTEff- CLAIMS-MADE C OCCUR PREMISES Ea occurrence f 100,000 MED EXP(Any one person) $5,000 A Y UDC4727063-CGL-21 02/03/2021 02/03/2022 PERSONAL BADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 X POLICY JET LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: _ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Me accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE : AUTOS ONLY AUTOS ONLY or accident f UMBRELLA LtAB OCCUR EACH OCCURRENCE $ EXCESS LIAe CLAIMS-MADE AGGREGATE $ DED RETENTION $ WORKERS COMPENSATION I PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTNE E.L.EACH ACCIDENT $ OFFICERIMEMBEREXCLUDED? ❑ NIA (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE f If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) CERTIFICATE HOLDER CANCELLATION VILLAGE RYE BROOK 938 KING ST RYE BROOK,NY 10573 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE --fir ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 'YO 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 part yt 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 Art Builders General Contractor LLC From:The Village of Rye Brook 892 North St White Plains,NY 10605-4436 PHONE:917-864-0313 FEIN:XXXXX7830 The location of where work will be performed is 15 Brook Lane,Rye Brook,NY 10573. Estimated dates necessary to complete work associated with the building permit are from September 28,2021 to December 15,2021. The estimated dollar amount of project is $10,001 -$25,000 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 a LLC,LLP,PLLP or a RLLP;OR is a partnership under the laws of New York State and is not a corporation. Other than the partners or members,there are no employees,day labor,leased employees,borrowed employees,part-time employees,unpaid volunteers(including family members)or subcontractors. Partners/Members: Astrit Rucaj 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 be employees under the Disability and Paid Family Leave Benefits Law.) I,Astrit Rucaj,am the Member 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 I 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 p1gal entity will immediately acquire appropriate New York State specific workers' compensation insurance and/or disability d paid family leanefits coverage and also immediately furnish proof of that coverage on forms approved by the Chair of the Workers'Compensa' n Board to the govent entity listed above. SIGN HERE Signature: Date: l J� 7 t Exemption Certificate ber eceived 2021-061146 September 28, 2021 NYS Workers'Compensation Board CE-200 01/2018