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HomeMy WebLinkAboutBP21-256PEfitM1T # j°al-- 5� i�ATE:, sECTioN � vS BLocr TYPE OF WORK Q /r � i0B LOCAT QN � OWNER hiI LS�,O/7P/J�So/� .�, CONTRACTt7 R EST. COST � TCO # FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING RGH PLUMBING GAS 0 SPRINKLER ELECTRIC LOW -VOLT 0 ALARM CJ AS BUILT FINAL �o/�/aa. f��j FEE DATE _- _ INSPEGTION RECORD DATE INSP I ci�� �L%-- r%OUci yawl / - o'l J� � /,�°�� ��ec74-i C �rvic.Q S i OTHER APPROVALS i ARB BOT PP ZBA OTHER VILLAGE OF RYE BROOK WESTCHESTER COUNTY, NEW YORK NO: 21-203 (ferttf tote of (9ccupaucp This is to certify that / / 1, � J 0�7 of, d , having duly filed an application on :0602m be jr' I -3T20,--;Z/ requesting a Certificate of Occupancy for the premises known as, / (a Arco�L d a/ /e , Rye Brook,NY, located in a �I C1 Zoning District and shown on the most current Tax Map as Section: '3 5.( 5 Block: / Lot: / and having fully complied with the requirements of the Building Code and the Zoning Ordinance under Building Permit No.C� ' of"i issued / 20 ;�/, such authority and permission is hereby granted to the property owner to lawfully occupy or use said premises or building or part thereof listed under the New York State Use Classification of: J (,�°�� - ,for the following purposes: 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. Lto o changes or rearrangement in the structural parts of the building or in the exit facilities shall be made,and no enlargement, hether by extending on any side or by increasing in height shall be made,nor shall the building be moved from one location another until a permit to accomplish such change has bee o to ilding Inspector.uilding Inspector,Village of Rye Brook: e: DEC 2 2021 v BUILDING TM ENT For office use onl : 3DPERMrr# 0) S6 DEC 13 2021 VILLAGE OF RYE BROOK ISSUED:/0— Y—Q 1 938 KING STREcT,RYE BRoox,NEW YORK 10573 DATE:/a/3.a 1 VILLAGE OF RYE BROOK (914)939-0668 FEE: 14 Vey PAM 13 BUILDING DEPARTMENT www.r^yebrookan 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 esrsrr►rrrrrrrrrrrrrrr»rssr»ss►sss•r••ssr»»sr►srr»»sr■s»s»»»»•rsrr»ss»srrrsrsrrsrsss•rrrrsrsrrrsr•rsrsrsssssssrsrsrsssssrrrss Address: /'�r A.lod0'e 211a 4 G Occupancy/Use: f 4C4eq Parcel M#: /3,, 65 Zone: 00- -1 0 Z Owner: /-�i��t = N�:/S��/ Address:-/G X4r vie ILle Ai"-* ZA4,Z 11)P1 P.E./R.A.or Contractor: Address: Person in responsible charge: �� S%/lr'�'C n��•. / Address: Application is hereby made and submitted to the Building Inspector of the Village of Rye Brook for the issuance of a/U�3j 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: Pif a Z S%�'off `<0k/' being duly sworn,deposes and says that he/she resides at 41 (Print Name of Applicant) (No.and Street) in &e /,/,;,1C ,in the County of �s fG S /Z in the State of kJ' that (Cityfrown/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:$ 00- U di for the construction or alteration of- 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.lofftthe Code of the Village of Rye Brook. Sworn to before me this J Sworn to before me this day of A—JL e-e`M_ 20P\ day of , 20 \� 1/74 T -"v`' Slgrifture of Property Owner Signature of Applicant ame of Property Owner Print Name of Applicant t Notary Public SHARI MELILLO Notary Public Notary Public, State of NewYvrk Na. 01 M P6160053 8/12/2021 Q-.ialiiied in Westch,.,ter County Commission Expires January 29,20Z21 Qyre,BRCdJ�• O� Zm W � BUILDING DEPARTMENT ILDING 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.or� - - - - - - -- - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - -- - -- - - - ADDRESS :_ V DATE: PERMIT# � 1 ISSUED: Q �ECT: BLOCK: LOT: LOCATION: ' ( �S�' " {} f v OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... ,D ACCEPTED ❑ REJECTED/REINSPECTION ❑ SITE INSPECTION �11 1 C u REQUIRED ❑ FOOTING I J ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ROUGH FRAMING ❑ INSULATION ❑ NATURAL GAS ❑ L.P.GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ C�ROSS CONNECTION FINAL ❑ OTHER e� IA N o W o a kn r, as old 16 '� y v% co �I O a © O Ow 00 V `p U W W � � o � � � z � � u � z V y 0 3a V O z H U6 F. U � o a .. ate. W a A W d ;D 1� bR(�tJ�` D L� C� �/ J BUILD 6�Eo'ARTMENT VIL 6 OF RYE)3ROOK SEP 3 Q 2021 938 KJNtitX ET RYE 131004,NY 10573 __ \ VILLAGE OF RY BROOK `r . BUILDIrJG DFpF- AF T or ELECTRICAL PERMIT APPLICATION Westchester County Master/Electricians License Required J FOR OFFICE USE ONLY BP#: - S EP#: OCT 0 4 2021 Approval Date: Permit Fee: $ Approval Signature: Other: Disapproved: IF (fees are non-refundable) ################################################################################################## Application dated, a 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. R1.Address: f 4 6 V0 0 K I a u'2 SBL: Zone: —Il/ 2.Property Owner: �+ep� e w ti O V1 Address: !!� Phone#: Cell#: I 37 4 '�Q 0 email: 5+1C y1 eH SD ar I. t'Gf1''►'1 3.Master Electrician: V l 0 SO W6 vd Address: Lic.#:1101-1 Phone#:QM-qq�-5�55ceH#: email: ^0�� �f �fLC GJc{�d{�, laWi Company Name: E-1 e A I [Q fS"G{'Vt ce 5 Address: 510 � t � k 1v akt fa_r'a P7t!C 1A 4.Proposed Electrical Work/Fixture Co t: � G L 2 I � O e ak r , [10L W eft- 4 e A , 1C77 Et 0&✓ U Ii aty STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: yi V1 c e v1 2 y Sa l v b vo a r,being duly sworn,deposes and states that he/she is the applicant above named,and does further (print name of individual signing as the applicant) rr l state that(s)he is the legal owner of the property to which this application pertains,or that(s)he is the F=(,e C 'I-I C( 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 y0A Sworn to befo a me this 0 1 day of ,20 9-1 day of 20; ,i SignafuA of Property Owner Signature of Applicant e —,ram . V10Cey12-a _ ggIL) Tr Print Name of Property Owner Print Name of Applicant teary Pu lic ALEXANDRA H.MARSHALL ALEXANDRA H.MARSHALL Notary Public,State of New York tiritary Public,State of New York No.OiFR6363711 No.01FR6363711 qualified in Westchester County,�,,cc qualified In Westchester County Commission Expires August 28,ZO`�V t3/lznozl �'nlomission Expires August 28,20� STATEWIDE • Service With hitegrity 1:1 Main Street,Fishkill, NY 12524 1 emoll:office@swisny.com SWIS JOB APPLICATION12.7224 1 fax 914.219.1062 1 SWISNY.com I SWISTraining.com Office Use Elect Permit# Date Bldg Permit# Utility ID# Final Certificate# City/Village Zip Township County Address Cross Street Section Block Lot Owner Name/Address(If different than above) Contact Number [:]Basement ❑1st FI. ❑2nd FL ❑3rd FI. ❑More Than 3 FI. ❑Garage ❑Attic ❑Outside ❑Residential ❑Commercial Receptacles Special Recept GFCI AFCI Switches Dimmers Smoke Alarms Carbon Monox Hood Trash Compact Amt Amps Range(s) Cooktop(s) Oven(s) Dishwashers Refrigerator Disposal Microwave Warm Draw Incandescent Fluorescent SERVICE Amperage Voltage 1 P 3P #Meters #Disconnect ❑Underground ❑ New ❑Reconnect ❑Overhead ❑ Change ❑Visual Re-Inspection ❑ Safety Re-Inspection ® Re-Inspection Additional Information t `LIZ SEP 3 0 2021] D i Vll_Lr`.GE OF RYE BROOK DEPARTMENT This application Is valid for one(1)year from the date received by SW15.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.The applicant declares that there is no open applications for the above address with any other Inspection company.The applicant,owner or authorized agent agrees to all the above terms and conditions as set forth for the application. Inspector Date Finalized Inspector# Company Name Date Signature Address City/State Zip Code License# Phone# AFFIDAVIT IN SUPPORT OF FEE WAIVER RELATED TO HURRICANE IDA STATE OF New o-k COUNTY OF 1/tI'2$+C ICI e<4 U I V C C v12 U S q V 60 tr (insert name), being duly sworn, deposes and says 1. 1 am the applicant for a Building Permit/Certificate of Occupancy / Demolition Permit lectrical Permit Plumbing Permit/Fence & Wall Permit Mechanical Permit/ Pod Permit(circle all that apply) 2. 1 am the legal owner of property located at /� az Rye Brook,New York (insert street address) 2R I am the �—�� (Architec Contractor Engineer/Attorney) (circle one) for the Cegalowner of ro � located at` 6 BY o L,0,tn-P . y e- B r u a K , Rye Brook,New York and I am duly authorized by property owner 5 e p� e yi 's 0 n to make and file the accompanying application. 3. The following is a description of(1) the work to be performed under the permit for which I am applying; and (2) how the work arose as a direct result of Hurricane Ida: I I G c e �l v v f j o*e,5; Gr t J de y' c e 5 4-1rc(4 w e-r e- -ed -t-o =L,4, (o o d daw e4 -exec-F�►cq ( tA, L4 j( r 4. The work described herein arose as a direct result of Hurricane Ida and does not include Work which was not caused by Hurricane Ida. f Sworn to before me this 3& Day of ?pkMV' 20 , Notary Public ALEXANDRA H.MARSHALL Notary Public,State of New York SE� � � ��2� No.01FR6363711 Quallf led In Westchester County Commission Expires August 28,20 15 State Wide Inspection Services CA� 1080 Main Street Fishkill, NY 12524 41 Al" 0 845 202-7224 Phone 914-219-1062 Fax STATE WIDE INSPECI ION SERVICES Email: OI IICe@$Wisny-com Website: www.swisny.com Service With Integrity BY THIS CERTIFICATE OF COMPLIANCE STATE WIDE INSPECTION SERVICES CERTIFIES THAT: Upon the application of: Upon Premises Owned by: Bolt Electrical Services Phil Stephenson Vincenzo Salubro,Jr. 16 Brook Lane 510 Jefferson Avenue Rye Brook, NY 10573 Mamaroneck, NY 10543 Located at: 16 Brook Lane, Rye Brook, NY 10573 Section: Block: Lot: Electrical Permit Number: EP21-251 135.65 Certificate Number: 2021-5119 Building Permit Number: BP21-256 A visual inspection of the electrical system was conducted at the Residential occupancy described below.The electrical system consisting of electrical devices and wiring is located in/on the premises at: 16 Brook Lane, Rye Brook,NY 10573 The First Floor was inspected in accordance with the NYS and NFPA 70-2017 and the detail of the installation,as set forth below,was found to be in compliance on the 13th day of December 2021. Name Quantity Rating Circuit Type Receptacles 25 GFCI 08 AFCI 06 Hood 01 Range 01 Dishwasher 01 Refrigerator 01 Microwave 01 s Officer: Frank 1. Farina This certificate may not be altered in any gray and is validated only by the presence of a seal at the location indicated.This certificate is valid for work perforated on the date of inspection only. ao I N N 00 o _96 ONO r I ~ boo 0 a a � Q Z O � az ki , - co a � W- 00 00F � z � 3 0Z o 0 a Q ° 1 CA z MEN � � z W ; W M ° (ON x x w c F IW owl W m 40, = nR D ECEEI] VE yE-�nv BUMP" E � �MENT VILE OF RYE OK NOV S 2421 938 Kllvc; S't' >tI RYE B ,NY 10573 VILLAGE OF RYE BROOK ` BUILDING DEPARTMENT or PLUMBING PERMIT APPLICATION FOR OFFICE USE ONLY BP#: PP#: CD Approval Date: NOV 19 2Q Permit Fee: $ Approval Signature: Other: /✓�� Disapproved: (face are non-refundable) Application dated, ��"�ti —a t is hereby made to the Building Inspector of the Village of Rye Brook NY,for the issuance of a Permit to install and/or remove Plumbing as per detailed statement described below.The applicant&property owner,by signing this document agree that said plumbing work will be in conformance with all applicable Federal,State,County and Local Codes. 1.Address: q- SBL: / �. 65 s// Zone: oe—ic 2.Proposed Work: tLW 3.Property Owner: ,y(/ S�f,Q/`�/Gr�<S[,q( Address: g1j&Wle I-A.1 / tf e 1�, x e Phone#: Cell#:! /y _�y _�Uu email:./,,", <I., � d 4.Master Plumber: % ' C� Q 1 Address: com Lie.#: �Phone#: (��,�!!' ��Cell#: 1 : W�+;� 1 }' Company Name: W Q `N� U Ass: r 5 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 I st Floor I 2nd Floor 3'Floor 4m Floor 5'Floor Exterior 5.*List Other E uipment/Pro a Details: v"q4 (Notarized Signatures Required Next 2 Pages) -1- 8/12/2021 STATE OF NEW YORK CCOUNTY OF WESTCHESTER ) as: V IM09-44- Z Rj ,being duly sworn,deposes and states that he/she is the applicant above named, (print name of individual signing is the applicant) and further states that(s)he its the legal owner of the property to which this application pertains,or that(s)he is the ��1JI A't�il'llt i � rC�'a� 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 '3 0 Sworn to before me s " day of hel- ,20�_ day o JV M �20aL— Si ature of Property Owner gign"ake of Applic Print Name of Property Owner Print Name of Applicant 'otary Publi ALVX NDRA H.MARSHALL Notary Public Notary Public,State of New York SHARI MEULLO No.01FR6363711 Notary Public, State of New York Qualifies!In Westchester County No. 01 ME61 e00O3 Commission Expires August 28,20-2L') 0,inlified in Westchester County This application must be properly completed in its entirety and�"�' fi4` a ni��ai�zedrys gitature 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 BUILDING DEPARTMENT VILLAGE OF RYE]BROOK NOV18 2021 938 KING STREET RYE BRooK,NY 10573 (914)939-0668 VILLAGE OF RYE BROOK www.aebrook.org BUILDING DEPARTMENT AFFIDAVIT OF COMPLIANCE VILLAGE CODE_ §216 - STORM SEWERS AND SANITARY SEWERS THIS AFFIDAVIT MUST BEAM 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 L »�i� Z �ri��% ,residing at, A,P�z*L L� °�,%�� '�2UurC �` �� (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; /� A'--)L-)v<Lz '—'/ , 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 storrnwater 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. (SignaftA of Property Owner(s)) Ale 4 //J (Print Name of Property Owner(s)) Sworn to before me this g�= day of (2_1( (Notary Public) Ll CHRISTOPHER J.BRADBURY Notary Public,State of New York No.01 BR6159985 3- Qualified in Westchester County Commission Expires January 29,2023=Z an2no21 AFFIDAVIT IN SUPPORT OF FEE WAIVER RELATED TO HURRICANE IDA STATE OF A COUNTY OF (insert name), being duly sworn, deposes and says 1. I am the applicant fora Building Permit/Certificate of Occupancy /Demolition Permit Electrical Permi Plumbing Perini /Fence & Wall Permit Mechanical Permit/ Pod Permit (circle all that apply) 2. 1 am the legal owner of property located at U e) 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 j � L�- , Rye Brook,New York and I am duly authorized by property owner PhA `�)4vph �A--5n^-) 14 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: L6L��' Q- LAI 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 Da of 1,�-erg d, 20_-�A_ SHARI MELILLO Notary Public, State cf New York Notary Public tit,, 01-!PLT61, r,,,33 �'I�!"i2d li- �'Jc>�CF':"iE?r COUnty Commission Exnirc;s January Th L� �` �E NOV 18 2021 VILLAGE OF RYE BROOK BUILDING DEPARTMENT Building Permit Check List&Zoning Analysis Address: I L ��D�Z -v�-r� SBL. L I Zone: i,-l -C-1 Use: Const.Type: Other. Submittal Date: -3 Z-f Revisions Submittal Dates: Applicant: -<-'1 ?-4 S n Nature of Work: I�`T�I ti � �- �9� �v`✓� � - Reviews:ZBA: PB: BOT: Other: LY) 2 OK ( ) (.'FEES:Filing. BP: C/O: Legalization: ( ) (� APP: Dated:- tarized ✓ SBL: Truss I.D. Cross Connection: H.O.A.: ( } ( ) Scenic Roads: Steep Slopes: Wetlands: Storm Water Review: Street Opening. ( ) ( ) ENVIRO:Long. Short Fees: N/A: ( ) ( ) SITE PLAN:Topo: Site Protections S/W Mgmt.: Tree Plan: Other. ( ) ( } SURVEY:Dated: Current: Archival• Sealed: Unacceptable: ( ( ) PLANS:Date Stamped: Sealed: Copies: Electronic Other. ( ( License: Workers Comp: Liability Comp.Waiver: ­"' Other. ( ) ( ) CODE 753#: Dated: N/A: (- ( ) HIGH-VOLTAGE ELECTRICAL:Plans: Permit N/A: Other. ( ) ( ) LOW-VOLTAGE ELECTRICAL:Plans: Permit: N/A Other: ( ) ( ) FIRE ALARM/SMOKE DETECTORS:Plans: Permit: H.W.LC.:_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: Permit: Fuel Type: Other. ( ) ( ) 2020 NY State ECCC: N/A: Other. ( ) ( ) Final Survey Final Topo: RA/PE Sign-off Letter. As-Built Plans: Other. ( ) { ) BP DENIAL LETTER: C/O DENIAL LETTER: Other. ( ) { } Other. { )ARB mtg. date; approval: notes: { )ZBA mtg.date: approval:- notes: { )PB mtg.date: approval: notes: REQUIRED EXISTING PROPOSED NOTES Data: c r� II_ 1021-. Circle: Fmntag Fmna_ Front: Sides: E&W Main Cov Accs,Cov F S : S .HS : Tot.in Ft IW: Par Hecht/Stories: notes: GEIC4 Insurance Agency, Inc. New Business Declarations Underwritten by Homesite Insurance For Policy Number 37308322 Company of New York, a Stock Company Policy Period This policy covers the listed 1 Federal Street location(s) From 12:01 AM February 12, 2021 Boston, MA 02081 Through 12:01 AM February 12, 2022(local time) Phone number: 1-866-372-8903 To Report a Claim: 1-866-621-4823 Phillip Stephenson Lorena Stephenson 16 BROOK LN RYE BROOK, NY 10573 Issued by Homesite Insurance Company of New York 'rns'ured Cocation 16 BROOK LN RYE BROOK NY 10573 Location ID: 000000058 Description of Dwelling 1950 Wood siding, Single family home, Primary residence Deductible— Other Covered Perils $1000 In case of hurricane loss under section 1, we cover only that part of the loss over the deductible stated. Hurricane Deductible 5% ($20350 Please refer to Important Messages Coverage Limit Premium Section I - Property Coverage A- Dwelling $407,000 $2,428.00 Coverage B-Other Structures $40,700 Included Coverage C - Personal Property $203,500 Included Coverage D- Loss of Use $122,100 Included Section Il - Liability Coverage E - Personal Liability $300,000 $173.00 Coverage F - Medical Payments to Others $1,000 $8.00 Coverage Modifications $12a-00 See Coverage Modifications on reverse side for details Additional Premium $0.00 See Additional Premium on reverse side for details Discounts -$514.00 See Discounts on reverse side for details Total $2,218.00 Authorized Representative Policy Number 37808322 HA D1 01 NY 11 17 n 10WrNrm042D210304YNNP#44Wta 70 yu e Coverage Modifications $123.00 Additional Limit Premium HA 23 85 1116 Limited Water Back Up and Sump Discharge or Overflow Coverage- New York $5,000 $30.00 HD-0171298 Deductible $226.00 HO 04 20 0511 Specified Additional Amount of Insurance for Coverage A-Dwelling 25% $52.00 HO 04 90 0511 Personal Property Replacement Cost Loss Settlement $267.00 Additional Premium $0 00 Limit Premium Discounts -$514.00 Limit Premium HA 80 80 0218 Hurricane Percentage Deductible - New York -$99 00 HD-063 1101 Drive Home Discount -$247.00 HD-086 0409 Welcome Home Discount -$116.00 HO 04 21 0502 Windstorm Protection Devices -$52.00 Contracts and Amendments HO 00 03 0511 Special Form (HO 00 03 0511) HA 01 31 1116 Special Provisions- New York HA 80 66 0520 Diminishing Deductible Credit HA 90 05 0417 Amendatory Endorsement- Pollution Exclusion HO 24 93 0502 Workers Compensation Policy Number 37808322 HA D1 01 NY 11 17 mzsan nn rmoa arwna veuiNHixs1 mxnm `+ew a o as Affidavit of Exemption to Show Specific Proof of Workers' Compensation Insurance Coverage for a 1, 2, 3 or 4 Family, Owner-occupied Residence **This form cannot be used to waive the workers'compensation rights or obligations of any pa►ty.** Under penalty of perjury, I certify that I am the owner of the 1, 2, 3 or 4 family, owner-occupied residence (including condominiums) listed on the building permit that I am applying for, and I am not required to show specific proof of workers' compensation insurance coverage for such residence because (please check the appropriate box): I am performing all the work for which the building permit was issued. I am not hiring,paying or compensating in any way,the individual(s)that is(are)performing all the work for which the building permit was issued or helping me perform such work. I have a homeowners insurance policy that is currently in effect and covers the property listed on the attached building permit AND am hiring or paying individuals a total of less than 40 hours per week (aggregate hours for all paid individuals on the jobsite) for which the building permit was issued. I also agree to either: ♦ acquire appropriate workers' compensation coverage and provide appropriate proof of that coverage on forms approved by the Chair of the NYS Workers' Compensation Board to the government entity issuing the building permit if I need to hire or pay individuals a total of 40 hours or more per week(aggregate hours for all paid individuals on the jobsite)for work indicated on the building permit,or if appropriate,file a CE- 200 exemption form; OR ♦ have the general contractor, performing the work on the 1, 2, 3 or 4 family, owner-occupied residence (including condominiums)listed on the building permit that I am applying for,provide appropriate proof of workers' compensation coverage or proof of exemption from that coverage on forms approved by the Chair of the NYS Workers' Compensation Board to the government entity issuing the building permit if the project takes a total of 40 hours or more per week(aggregate hours for all paid individuals on the jobsite)for work indicated on the building permit. ` / 513d �`,(Signature of Homeowner) (Date Signed) 1-e ����� ��^ / Home Telephone Number �/ �` 7t)o (Homeowner's Name Printed) Sworn to before me this day of Property Address that requires the building permit: e3O t{ �c z ounty—`Clerk o otary Public) ALEXANDRA H.MARSHALL Notary public,State of New York No.01FR6363711 Qualified In Westchester County o ' Once notarized,this BP-1 form serves as an exemption for both workers'compensation and disability benefits insurance coverage. BP-1 (12/08) NY-WCB